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    Patients


Satisfaction Questionnaire

Please take a moment to fill out the questions below so that we may better improve our service to our patients. Thank you for your consideration.


Name (optional):
Location:
Date of Surgery:
Surgeon/Gastroenterologist:


1. My anesthesiologist adequately explained the anesthetic plan and answered all my questions to my satisfaction before the procedure.
    Strongly agree
    Somewhat agree
    Neither agree or disagree
    Somewhat disagree
    Strongly disagree
2. My anesthesiologist treated me in a professional and respectful manner.
    Strongly agree
    Somewhat agree
    Neither agree or disagree
    Somewhat disagree
    Strongly disagree
3. I was comfortable (pain free) after my procedure.
    Strongly agree
    Somewhat agree
    Neither agree or disagree
    Somewhat disagree
    Strongly disagree
4. I am satisfied with the anesthetic care I received.
    Strongly agree
    Somewhat agree
    Neither agree or disagree
    Somewhat disagree
    Strongly disagree


Would you like us to contact you regaurding your experience?
Yes    No

If you chose "Yes", please let us know how you would like us to contact you: EMAIL PHONE OTHER
And fill out the additional information below:
Phone Number:
Email Address:
Additional Comments:




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