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Your opinion makes all the difference to us.  We care what you think.  We want your experience to the best it can.  We think that means the friendliest, most responsive staff, providing personal, professional service.  But, what do you think?  Won’t you PLEASE take a few minutes of your time and let us know what you like (or don’t like) about our services.  Any comments would be appreciated.  We thank you in advance for completing this questionnaire and offering us your opinion.  

 Background Questions (Write in answer or check as appropriate.) 

1.  Date of Procedure?                                 2.  Patient’s sex         ____Male   ____Female

          _ _/_ _/_ _ _ _

           Mo     day         year

3.  Was this your first visit as a patient to our

     Ambulatory Surgery Center?     ____Yes   ____No  

INSTRUCTIONS:  Please rate the outpatient surgery you received from our facility. Circle the number that best describes your experience.  If a question does not apply to you, please skip to the next question.  Space is provided for you to comment on good or bad things that you may have experienced during your visit.

A.      Registration                                                                             Poor         Poor        Fair      Good    Good

1.  If you spoke with the Surgery Center by phone

     helpfulness of the person you spoke with………………………………...     1         2          3          4          5

2.  Ease of getting an appointment for surgery when you wanted…………..        1         2          3          4          5

3.  Information you received prior to surgery (i.e.,

     time of surgery, how to prepare)…………………………………………    1         2          3          4          5

4.  Helpfulness of the person at the registration desk (upon arrival)………...       1         2          3          4          5

5.  Financial responsibility for your procedure was explained

      to you in adequate detail…………………………………………………   1         2          3          4          5

COMMENTS (Describe good or bad experience): ___________________________________________

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B.      Facility

1.  Comfort of the registration waiting area…………………………………      1         2          3          4          5

2.  Comfort of your room or resting area in the Center……………………...     1         2          3          4          5

3.  Comfort of the waiting area for your family……………………………..      1         2          3          4          5

4.  Attractiveness of the Surgery Center……………………………………..    1         2          3          4          5

5.  Cleanliness of the Surgery Center………………………………………..    1         2          3          4          5

COMMENTS (Describe good or bad experience): ___________________________________________

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C.  Before Your Surgery or Procedure                                                                                                                  Poor         Poor        Fair      Good    Good

1.  Waiting time before your surgery or procedure began…………………...    1         2          3          4          5

2.  Friendliness/courtesy of the physician…………………………………...      1         2          3          4          5

3.  Explanation the physician gave you about what the

     surgery or procedure would be like………………………………………    1         2          3          4          5

4.  Friendliness/courtesy of nurses…………………………………………..     1         2          3          4          5

5.  Skill of nurse starting IV…………………………………………………    1         2          3          4          5

6.  Information nurses gave you on the day of your procedure……………..      1         2          3          4          5

COMMENTS (Describe good or bad experience): ___________________________________________

_____________________________________________________________________________________

D.  After your Surgery or Procedure

1.  Nurses’ concern for your comfort after the procedure…………………...     1         2          3          4          5

2.  Nurses’ courtesy toward family who accompanied you

     (if applicable)…………………………………………………………….   1         2          3          4          5

3.  Information nurses gave your family after your surgery…………………        1         2          3          4          5

4.  Instructions nurses gave you about caring for yourself at home…………        1         2          3          4          5

5.  Your confidence in the skill of the nurses………………………………..      1         2          3          4          5

6.  Your confidence in the skill of the physicians…………………………....       1        2         3          4          5

COMMENTS (Describe good or bad experience): ___________________________________________

_____________________________________________________________________________________

E.  Personal Issues

1.  Information provided about delays (if you experienced delays)…………       1         2          3          4          5

2.  Our concern for your privacy…………………………………………….    1         2          3          4          5

3.  Degree to which your pain was controlled……………………………….     1         2          3          4          5

4.  Response to concerns/complaints made during your visit……………….       1         2          3          4          5

COMMENTS (Describe good or bad experience): ___________________________________________

_____________________________________________________________________________________

F.  Overall Assessment

1.  Overall rating of care received during your visit………………………...       1         2          3          4          5

2.  Degree to which staff worked together to care for you…………………..     1         2          3          4          5

3.  Likelihood of your recommending our Ambulatory

     Surgery Center to others………………………………………………….  1         2          3          4          5

COMMENTS (Describe good or bad experience): ___________________________________________

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OVERALL COMMENTS:  Please use the space below to provide us with suggestions that you feel would help us improve the care that we provide.

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How did you hear about MicroSpine?_______________________________________

Patients Name: (Optional): ___________________________ Telephone Number: (Optional)_____________

Fax To 850-892-4212