ASPC Patient Satisfaction Survey

Athens Spine Procedural Center Patient Satisfaction Survey

Thank you for choosing Athens Spine Procedural Center for your procedure. We hope that your experience during your time in our center was positive. Your comments and suggestions are important to us. Please assist us in continuing to provide the highest level of care possible by completing the short survey below.
General Information
Patient Name (Optional)

First Name Last Name
Physician Name *

First Name Last Name
Date of Procedure

Month Day Year
Date
Phone Number (Optional)
Please enter a valid phone number.
Email (Optional)
example@example.com
Facility and Staff Information

1) Please rate your satisfaction of the following areas:

	Not Satisfied	Somewhat Satisfied	Satisfied	Very Satisfied
Overall Impression of Facility
Cleanliness of Facility
Friendliness of Reception Staff
Check-In Process
Friendliness of Nursing Staff
Friendliness of Physician
Privacy respected at all times
Billing/Insurance Information was clear

2) I received all information that I needed about my procedure from the physician or staff prior to the procedure.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
3) The Receptionist was courteous and helpful.

1

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3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
4) My wait time prior to my procedure was reasonable and as expected.

1

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4

5

1 is Strongly Disagree, 5 is Strongly Agree
5) How long did you have to wait for your procedure beyond your scheduled appointment time?

My appointment was on time 0-30 Minutes 30-60 minutes Over 60 minutes
6) The pre op nursing staff were courteous and explained things in a way that I could understand before my procedure.

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3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
7) My physician spent adequate time with me explaining my procedure in a way that I could understand and answering all questions.

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3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
8) The operating room staff were courteous and made sure I was as comfortable as possible during my procedure.

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4

5

1 is Strongly Disagree, 5 is Strongly Agree
9) The Recovery staff were helpful and gave discharge instructions to include symptoms to watch for after the procedure, medications, and follow up appointments.

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3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
10) I received written discharge instructions that were clear and helpful.

1

2

3

4

5

1 is Strongly Disagree, 5 is Strongly Agree
11) Using the numbers 0-10, with 0 being the worst possible and 10 being the best possible, what number would you use to rate Athens Spine Procedural Center?

1

2

3

4

5

6

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8

9

10

1 is Worst, 10 is Best
12) Would you recommend Athens Spine Procedural Center to your family and friends?

Definitely yes Maybe yes Maybe no Definitely no
Please feel free to leave any comments for areas that you feel we excelled or suggestions for areas that we can improve:
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Athens Spine Procedural Center Patient Satisfaction Survey

General Information

Facility and Staff Information