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*Date of Service:		*Physician: Alfred, Richard, H. M.D. Alley, R. Maxwell, M.D. Bagchi, Kaushik, M.D. Carl, Allen L., M.D. Cheney, Robert A., M.D. Czajka, John, M.D. Das, Shankar P., M.D. DiPreta, John A., M.D. Fuchs, Marc D., M.D. Gerdeman, Andrew, M.D. Hedderman, Robert J., M.D. Hospodar, Paul P. M.D. Iqbal, Anjum, M.D. Lawrence, James P., M.D. Lisella, Jordan M. M.D. Lozman, Jeffrey, M.D. Mulligan, Michael, M.D. Phelan, Daniel T., M.D. Quinn, David E., M.D. Schneider, James M., M.D. Striker, James E., M.D. Toussaint, Jon, M.D. Uhl, Richard L., M.D. Whipple, Richard R., M.D. Zanaros, George, M.D.
Scale Definition: 1-Poor 2-Below Average 3-Average 4-Good 5-Excellent N/A
		1 2 3 4 5 N/A
1. *Reception and registration process
2. *Pre-operative telephone call or visit
3. *Care provided by the nursing staff before your procedure
4. *Interaction with the anesthesia
5. *Interaction with the nursing staff in the operating room
6. *Care provided by the recovery room staff
7. *Protection of your privacy
8. *Cleanliness and appearance of the center
9. *Your overall confidence in the care provided to you by the staff
10. *Overall Center experience
Please fill bubble to indicate YES or NO to the following questions.
		YES NO
11. *Would you recommend the Center to family members or friends?
12. *Did you receive discharge instructions?
13. *Were the instructions clear?
Please submit your written responses to the following questions in the boxes provided below.
*What did you like best about your experience at the Center?
*What did you like least about your experience at the Center?
*Any other comments?
Thank you taking the time to complete this survey and share your ideas!

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