In an effort to continually provide the best service to out patients, we are asking you to complete this survey. Your input and feedback will help us to continue to improve upon the care we bring pour patients.

Admitting / Registration

Professional & Courteous Service
Excellent Good Needs Improvement 

Speed & Efficiency of Registration
Excellent Good Needs Improvement 

Satisfactory Answers to Questions
Excellent Good Needs Improvement 

Nursing

Professional & Courteous Service
Excellent Good Needs Improvement 

Nurses Introduced Themselves & Kept You Informed
Excellent Good Needs Improvement 

Satisfactory Answers to Questions
Excellent Good Needs Improvement 

Written Instructions for Home Care
Excellent Good Needs Improvement 

Overall

Staff Gave You Privacy
Excellent Good Needs Improvement 

Cleanliness & Comfort of Care
Excellent Good Needs Improvement 

Likelihood You Would Return or Recommend Our Center
Excellent Good Needs Improvement 

Overall Rating of Your Experience
Excellent Good Needs Improvement 

Additional Comments

Name (Optional)