Cornerstone Surgery Center

4780 North Josey Lane
Suite 104
Carrollton, TX 75010

Phone: (972) 395.0440
Fax: (972) 395.0460


Patient Satisfaction Survey

INSTRUCTIONS: Please rate the outpatient surgery you received from our facility. Select the phrase that best describes your experience. If a question does not apply to you, please skip to the next question.

Red/Bold = Required

Background Questions
Type in answer or click radio button as appropriate
Date of Procedure
Patient's Sex
Patient's Age
Years
Physician
Was this your first visit to our Ambulatory Surgery Center?
Patient's Name (optional)
Telephone Number (optional)
 
A. Registration
Professional and courteous service of registration
Satisfactory answers to financial and insurance questions
Speed and efficiency of registration
 
B. Facility
Comfort of the registration waiting area
Comfort of your seat or resting area in the Center
Attractiveness of the surgery center
Cleanliness of the surgery center
 
C. Nursing
Waiting time before your surgery or procedure began
Explanation the physician gave you about the surgery or procedure
Professional and courteous service of the nurses
Skill of the nurse starting IV
Nurses explaining procedures
Nurses concern for your comfort
Nurses courtesy towards family who accompanied you (if applicable)
Instructions nurses gave about caring for yourself at home
 
D. Personal Issues
Information provided about delays (if you experienced delays)
Our concern for your privacy
Degree to which your pain was controlled
Response to concerns/complaints made during your visit
 
E. Overall Assessment
Overall rating of care received during your visit
Degree to which staff worked together to care for you
Likelihood of your recommending our Ambulatory Surgery Center to others
Comments (describe good or bad experiences):
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Copyright 2008 Cornerstone Surgery Center
4780 North Josey Lane, Suite 104 • Carrollton, TX 75010
Phone: (972) 395.0440 • Fax: (972) 395.0460

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only and is not a substitute for direct medical advice or treatment for specific medical conditions.

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