Patient Satisfaction Survey

Tell Us About Your Experience

Patient Name (optional)
First Last
Physician*
Date of Service*
Date Format: MM slash DD slash YYYY
Reason for Visit*
- Inpatient Surgery
- Outpatient Surgery
Receptionist*
Excellent Good Fair Poor Does Not Apply
Friendliness / courtesy of Receptionist
Phone calls answered promptly
Scheduling*
Excellent Good Fair Poor Does Not Apply
Friendliness / courtesy of Schedulers
Knowledge of pre-op information
Answering questions effectively

Pre-operative Testing*

	Excellent	Good	Fair	Poor	Does Not Apply
Timeliness of pre-op testing
Friendliness / courtesy of Radiology Tech
Friendliness / courtesy of Laboratory Tech
Friendliness / courtesy of Cardiology Tech
Knowledge/skill of Technician

5th Floor Nursing*
Excellent Good Fair Poor Does Not Apply
Friendliness / courtesy of Nurses
Knowledge / skill of Nurses
Responsiveness of Nurses to your needs
Discharge instructions clearly explained
Surgery Nurses/Staff*
Excellent Good Fair Poor Does Not Apply
Friendliness / courtesy of Surgery Staff
Skill of Surgery Nurses / Staff
Responsiveness of Nurse to your needs
Explanation of procedures
Dietary/ Serving Staff*
Excellent Good Fair Poor Does Not Apply
Friendliness / courtesy of Serving Staff
Inpatient - Quality of Food
Outpatient - Quality of Snack & Beverage
Dietary needs met
Hospital Accommodations*
Excellent Good Fair Poor Does Not Apply
Cleanliness of hospital room
Overall comfort
Omega Hospital, LLC*
Excellent Good Fair Poor Does Not Apply
Overall Satisfaction with Omega Hospital, LLC
Additional Comments / Suggestions:
Name
This field is for validation purposes and should be left unchanged.

	Excellent	Good	Fair	Poor	Does Not Apply
Friendliness / courtesy of Nurses
Knowledge / skill of Nurses
Responsiveness of Nurses to your needs
Discharge instructions clearly explained

	Excellent	Good	Fair	Poor	Does Not Apply
Friendliness / courtesy of Surgery Staff
Skill of Surgery Nurses / Staff
Responsiveness of Nurse to your needs
Explanation of procedures

	Excellent	Good	Fair	Poor	Does Not Apply
Friendliness / courtesy of Serving Staff
Inpatient - Quality of Food
Outpatient - Quality of Snack & Beverage
Dietary needs met