Bethesda Chevy Chase Surgery Center


Survey Form


* Patient Name

* Email ID

* Date of Surgery

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


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


How long did you wait past your appointment time?


Choose one of the following answers

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


Choose one of the following answers

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


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


Did you experience adequate pain relief prior to discharge?


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?


Would you recommend the Surgery center to family or friends?


How do you rate your overall experience?


Choose one of the following answers

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