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Procedure Type: Surgical Colonoscopy/Endoscopy Pain Mgmt Other
Date of Procedure:
Name (Optional):
Doctor's Name (Optional):
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1. Information and instructions given to you before your procedure:
2. Registration staff explanation about billing and insurance information:
3. Informaiton given to you regarding the potential risks complication of type of anesthesia you reveived:
4. Courtesy and professionalism of the nursing staff toward you and your family member/caregiver:
5. Level of personal interest and care you received from your doctor:
6. Protection of confidentiality and personal privacy:
7. Cleanliness and comfort of facility:
8. Managemnt of pain after your procedure
9. Instructions given to you upon discharge:
10. Your experience and the care you recieved at our facility:
11. Did you experience any unexpected problems after your procedure? Yes No
If yes, please explain:
12. What did you like most about the facility?
13. What did you like least about the facility?
14. Would you recommend this facility to your family and friends? Definitely Yes Probably Yes Probably Not Definitely Not
15. Please list any other comments, suggestions, or employees who provided exceptional service: