Patient Satisfaction Form

Dear Patient,
Your thoughts and comments are very important to us. Your response will help us to improve our service to you and others. Thank you for your response.

Admitting / Registration

1. Office Staff was professional and courteous
Excellent Good Poor Very Poor

2. Registration was efficient and accurate
Excellent Good Poor Very Poor

3. Financial and insurance questions were answered to your satisfaction
Excellent Good Poor Very Poor

Nursing

4. Nursing Care was done with courtesy and respect
Excellent Good Poor Very Poor

5. Nurses introduced themselves and kept you informed
Excellent Good Poor Very Poor

6. Nurses explained procedures in a way you could understand
Excellent Good Poor Very Poor

7. Questions were answered to your satisfaction
Excellent Good Poor Very Poor

8. Written instructions were provided for your home care
Excellent Good Poor Very Poor

Overall

9. Staff provided you the privacy you needed
Excellent Good Poor Very Poor

10. Sheboygan Surgery Center was clean and comfortable
Excellent Good Poor Very Poor

11. Likelihood that you would return or recommend the Sheboygan Surgery Center to family or friends
Excellent Good Poor Very Poor

12. Overall rating of your experience at the Sheboygan Surgery Center
Excellent Good Poor Very Poor

Additional Comments:

Optional Information

Name:

Street, Apt. and/or Unit Number:
City: State: Zip:

3141 Saemann Avenue • Sheboygan, WI 53081 (920) 783-5000 • www.sheboygansurgerycenter.com

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