Patient Survey
Please help us continue to improve our services by filling out this short survey of your experience with Vascular Wellness.
Please tell us the name of the nurse who performed your procedure:
*
*If you are unsure of the name, please write "unsure"
Please tell us the name of the facility where you received treatment:
*
Please provide us with your age range:
*
18-24
35-44
55-64
25-34
45-54
65 and older
Please tell us about the nurse that performed the procedure:
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
The nurse introduced himself/herself
The nurse explained the procedure
The nurse answered my questions
The nurse addressed my concerns
The nurse cleaned up after the procedure
The nurse arranged the room back to how it was or how I reasonably directed
The nurse was professional
The nurse was courteous
The nurse respected my privacy when visitors were present in the room
On a scale of 1-5, with 5 being the best, please rate how well we satisfied your clinical needs.
*
★
★★
★★★
★★★★
★★★★★
satisfaction scale 1-5
On a scale of 1-5, with 5 being the best, please rate your overall experience.
*
★
★★
★★★
★★★★
★★★★★
satisfaction scale 1-5
Please share any details or additional comments about your experience:
If you have questions or would like a response to your submission, please provide your contact information and additional details:
Submit
Should be Empty:
Now create your own Jotform - It's free!
Create your own Jotform