Golf Surgical Center
8901 Golf Road
Des Plaines, IL 60016
847-299-CARE
847-299-2297
ph:
fax:

Patient Satisfaction Survey

Thank you for completing this questionnaire. Your feedback is very important to us.

Survey Code:

Please rate your agreement with the following statements:
Date of Service: mm/dd/yyyy

Registration
Helpfulness of the person at the registration desk
Ease of registration process
Waiting time in registration area
Facility
Comfort of waiting area
Cleanliness of facility
Our Nursing Care
Friendliess/courtesy of staff who provided treatment
Skill of the staff who provided treatment
Staff's concern for comfort
Staff's concern for your questions and worries
Personal Issues
Our concern for your privacy
Our sensitivity to your needs
Response to concerns/complaints during your visit
Our Anesthesia Staff
The anesthesiologist was courteous and friendly
The anesthesiologist spent time reviewing my anesthesia care and answering my questions
Your Surgeon
My surgeon was courteous and friendly
My surgeon spent time explaining my procedure and answering my questions
My Recovery
My pain level was as expected and well controlled
Adequate time was allowed for my recovery
My homecare instructions were clean and helpful
Home Follow-Up
When I was contacted at home, the clinical staff was concerned for my progress and comfort and answered my questions
Overall Assessment
Overall rating of care received during visit
Likelihood of your recommending our facility to others

Any comments or suggestions? (Describe good or bad experience)

Would you like to be contacted to discuss any concerns?
If you have any medical questions or concerns, please contact your surgeon.

Your Name (optional):

Your Phone Number (optional):