Questionnaire

Thank you for allowing Herndon Surgery Center to provide your healthcare services.

Please let us hear from you.

We would like to know what you thought of your care while at our Surgery Center.
Please be candid.
Your comments allow us to improve our services.
There is no need to sign provide your name unless you wish to identify yourself.

Reception Business Area Staff

Courtesy
Promptness
Were all of your questions answered to your satisfaction?

Nursing Staff

Professionalism
Promptness
Were all of your questions answered to your satisfaction?

Surgeon

Professionalism
Caring
Did your surgeon talk with you prior to surgery?
Were all of your questions answered to your satisfaction?

Anesthesiologist

Professionalism
Caring
Were you introduced to an anesthesiologist before surgery?
Were all of your questions answered to your satisfaction?

The Surgery Center

Comfort
Cleanliness
Were your expectations met?

Miscellaneous

Comfort
Cleanliness

Do you feel Herndon Surgery Center offered the following benefits?

Convenience
Personal Attention
Quality Care

Would you recommend Herndon Surgery Center to a friend or relative?

Would you recommend Herndon Surgery Center to a friend or relative?

Additional Comments & Suggestions

Patient Information (Optional)

Name
Address
MM slash DD slash YYYY