COE PATIENT SURVEY

COE PATIENT SURVEY
Please tell us your opinion about the service you received from the Center of Excellence you corresponded with or visited. Scores and comments will be shared with the center, but your personal information will remain confidential unless you indicate otherwise.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
Remain Anonymous*

YesNo
Are You*

Self/PatientParent/Caregiver of PatientHealthcare Professional
Credentials
Job Title
Employer/Institution
Is Patient*

New PatientReturning Patient
Patient's Age*

Under 1818 and over
I confirm that I am the parent/caregiver of the patient.
RATE YOUR COMMUNICATION WITH THE CENTER
Which COE did you interact with?*
Date of correspondence/appointment*
Did you access the Center's website?*

YesNoN/A - Does Not Apply
Did you find relevant information?

YesNo
Did you call the Center?*

YesNoN/A - Does Not Apply
Were you directed to the appropriate service?

YesNo
Did you email the Center?*

YesNoN/A - Does Not Apply
Did you receive a response?

YesNo
TELL US ABOUT YOUR VISIT WITH THE CENTER

Please note: LD = Lymphatic Disease
Did the patient receive instructions regarding follow-up care?*

YesNoN/A - Does Not Apply
Did the patient receive advice on ways to manage their LD?*

YesNoN/A - Does Not Apply
Did the patient receive referrals to other LD professionals, if applicable?*

YesNoN/A - Does Not Apply
Was the patient given a LE&RN welcome packet?

YesNoN/A - Does Not Apply
Was the patient given information about the LE&RN Global Registry for LD?

YesNoN/A - Does Not Apply
Was the patient provided information about any LD patient education?

YesNoN/A - Does Not Apply
Was the patient provided information about any LD support groups?

YesNoN/A - Does Not Apply
YOUR OVERALL SATISFACTION WITH:
The Center*

5 - Excellent4 - Very Good3 - Good2 - Fair1 - Poor
Quality of the patient's medical care*

5 - Excellent4 - Very Good3 - Good2 - Fair1 - PoorN/A - Does Not Apply
Would you recommend the Center to others?*

YesNo
Please tell us why:
Is there any way the Center can improve their services?
Would you be willing to serve on an Affiliate Board consisting of patients and Center staff dedicated to improving services?*

YesNo
Thank you for completing the COE Patient Survey. If you have any questions, please contact LE&RN.

Lymphatic Education & Research Network
154 W 14th St, 2nd Floor
New York, NY 10011
516-625-9675
coe@lymphaticnetwork.org
https://lymphaticnetwork.org/
Should be Empty:

COE PATIENT SURVEY

RATE YOUR COMMUNICATION WITH THE CENTER

TELL US ABOUT YOUR VISIT WITH THE CENTER

YOUR OVERALL SATISFACTION WITH: