1. Information and instructions given to you before your procedure:
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2. Registration staff explanations about billing and insurance information:
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3. Information given to you regarding the potential risks/complications of type of anesthesia you received.
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4. Courtesy and professionalism of the nursing staff toward you and your family member/care giver.
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5. Level of personal interest and care you received from your doctor.
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6. Protection of confidentiality and personal privacy.
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7. Management of pain after your procedure.
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8. Instruction given to you upon discharge.
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9. Cleanliness and comfort of the facility.
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10. Your overall experience and the care you received at our facility.
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11. Did you experience any unexpected problems after your procedure?
If YES, please explain.
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12. What did you like most about the facility?
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13. What did you like least about the facility?
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14. Would you recommend the facility to your family and friends?
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15. Please list any general comments, suggestions or employees who provided exceptional service.
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Type of Procedure:
If Other please explain below:
Other:
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Date of Procedure:
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Name (Optional):
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Doctor's Name (Optional):
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Your name is optional, but it gives us the opportunity to get in touch with you regarding your stay with us. I value your opinion as a customer of ours and thank you for taking the time to share it. Your responses will be kept in strict confidence.
Mabel Guerrero - Administrator
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