Patient Satisfaction Survey - MMH Emergency Department
Full Name (Optional: You may leave blank. This is helpful if you'd like for us to call you or reach out about your experience.)
First Name
Last Name
If you'd like a response back, please enter your email here:
example@example.com
If you'd like to receive a call, please enter your phone number here:
Please enter a valid phone number.
Date/Time of Your Visit
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
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Registration Process Survey
How long did you wait to be registered?
*
Please Select
Immediately
Under 5 minutes
Under 10 minutes
Over 10 minutes
Over 15 minutes
Over 20 minutes
Longer than 30 minutes
Was the Registration staff friendly?
*
Please Select
Yes
No
Was the Waiting Room Clean?
*
Please Select
Yes
No
Was the Registration process quick and easy?
*
Please Select
Yes
No
Was the TV on and at an appropriate volume level?
*
Please Select
Yes
No
Was the bathrooms stocked and clean?
*
Please Select
Yes
No
Did not go into bathrooms
If you answered "No" to any question above, please tell us why:
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Emergency Department Survey
Physicians/Providers Name in Emergency Room (If you know it)
Nurses Name (If you know it)
Any other staff you want to mention?
*
Was your room clean?
Please Select
Yes
No
Was all staff friendly and compassionate?
*
Please Select
Yes
No
Did our team address your medical concerns?
*
Please Select
Yes
No
Did you receive written discharge instructions?
*
Please Select
Yes
No
If you answered "No" to any question above, please tell us why:
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Your Feedback
Our goal is to provide exceptional patient care in everything that we do. If we fail, we want to know about it. If we did a fantastic job, we'd like to hear that, too. Please detail your experience as much as you would like to here.
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How likely are you to recommend?
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Please Select
5 - Very Likely
4 - Likely
3 -Neutral
2 - Not Likely
1 - Absolutely Not
Would you like to get emails about happenings, news and events at MMH?
*
Yes, I would
No, I would not
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