Doctor's Name Date of Surgery/Procedure Were you treated courteously at all times? - None -YesNo Please rate how satisfied you were with your surgeon’s care. - None -Very UnsatisfiedUnsatisfiedNeutralSatisfiedVery Satisfied Please rate how satisfied you were with your anesthesiologist’s care. - None -Very UnsatisfiedUnsatisfiedNeutralSatisfiedVery Satisfied Were your discharge instructions clear and helpful? - None -YesNo How would you rate your comfort level in the recovery area? - None -PoorFairGoodVery goodExcellent How would you rate the preoperative and postoperative care? - None -PoorFairGoodVery goodExcellent How would you rate the office staff’s willingness to work with your insurance and payment situation? - None -PoorFairGoodVery goodExcellent Did everyone introduce themselves prior to caring for you? - None -YesNo In your preoperative phone call, how would you rate the nurse’s explanation and answers to your questions about surgery? - None -PoorFairGoodVery goodExcellent How likely are you to use OAK Surgery Center for further surgery needs? - None -Extremely LikelyLikelyUnsureUnlikelynot at all likely Were there any problems you didn’t anticipate? - None -YesNo How could we have made your visit more pleasant? Name Telephone Number Convenient Time to Call Submit