Online Patient Feedback Survey

Please do not include any personal health information as this form is not encrypted.   

...

Name

Phone Number

Email

Date

Are we serving you as?

PatientFamily Member/FriendVisitor

What department(s) did you utilize?:

RegistrationLaboratoryRadiologyNursingSurgery Physical Therapy Wound CareRespiratoryOther

Other:

Did our staff introduce themselves?

YesNo

Did our staff explain procedures/care?

YesNo

Did our staff tell you how long it would take?

YesNo

Did our staff thank you for choosing the hospital?

YesNo

Would you refer us to your friends and family?

YesNo

Comments regarding your visit today -OR- staff to recognize

Submit