Patient Feedback Form Patient_Feedback_Form We at Norwood Day Surgery are committed to providing the highest standard of care to our patients. Your feedback is invaluable to us for improving our services and ensuring we meet your needs effectively. We kindly ask that you take a few moments to complete this survey. Your responses are confidential, and we assure you that all information will be used strictly for quality improvement purposes. Your First & Last Name - (Optional) Please enter your name above if you are comfortable doing so. This is entirely optional; you may also proceed with the survey anonymously. Your feedback will be equally valued whether or not you choose to identify yourself. Your Surgery Date * Were you a: * Self Insured Patient Private Heath Insured Patient Were you made aware of your ‘Rights and Responsibilities’? Please Select... Yes No Did you understand your Rights & Responsibilities? Please Select... Yes No Did you feel well informed about your health care? Please Select... Yes No Were you involved in your plan of care as much as you wanted to be? Please Select... Yes No Were the staff polite, professional, respectful, considerate and listened well? Please Select... Very Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied Were the staff polite, professional, respectful, considerate and listened well? - Comment Were you happy with the quality of care you received? Please Select... Very Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied Were you happy with the quality of care you received? - Comment Was your environment clean and comfortable? Please Select... Very Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied Was your environment clean and comfortable? - Comment How well was your pain controlled? Please Select... Very Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied How well was your pain controlled? - Comment Did the nurses and doctors explain things in a way you could understand? Please Select... Very Satisfied Satisfied Neither Satisfied nor Dissatisfied Dissatisfied Very Dissatisfied Did the nurses and doctors explain things in a way you could understand? - Comment Did you view staff practicing Hand Hygiene? Please Select... Yes No On discharge were you provided with information on site infection or antibiotics? Please Select... Yes No Do you have any suggestions for improvements or feedback? Do you wish to be contacted regarding your feedback? Please Select... Yes No Your Email - (Optional) Please enter your email above if you are comfortable doing so. This is entirely optional; you may also proceed with the survey anonymously. Your feedback will be equally valued whether or not you choose to identify yourself. If you are human, leave this field blank. Submit if (is_page('Consumer Information')) { // Display contact form if the page is Contact } else { }
