Bethesda Chevy Chase Surgery Center

Bethesda Chevy Chase Surgery Center

Survey Form

* Patient Name

Answer

* Email ID

Answer

Date Of Surgery

Year-Month-Day

Help

Date Of Surgery

Do you feel your patient confidentiality was maintained at the front desk upon admission?

Yes
No

Do you feel that you received a satisfactory explanation of your financial responsibility?

Yes
No

How long did you wait past your appointment time?

Choose one of the following answers

Did not wait
1 – 15 minutes
15 – 30 minutes
Over 30 minutes

If you waited past your appointment time, were you informed of any delays?

Choose one of the following answers

Yes
No
N/A

Do you feel you received clear and complete explanation of your procedure by the anesthesiologist and your surgeon?

Yes
No

Was the nursing staff responsive to you and your family’s needs?

Yes
No

Did you experience adequate pain relief prior to discharge?

Yes
No

Do you feel that you received clear and complete explanation regarding how to care for your condition at home, and what signs and symptoms to watch for?

Yes
No

Would you recommend the Surgery center to family or friends?

Yes
No

How do you rate your overall experience?

Choose one of the following answers

Excellent
Good
Fair
Poor

Please give us any suggestions as to how your visit to the surgery center could have been better.

Answer