Patient Questionnaire

Thank you for choosing Middlesex Center for Advanced Orthopedic Surgery for your procedure.  We hope that your experience was a positive one and that you are well on your way to recovery.

Your comments and suggestions are very important to us.  Please assist us in continuing to provide the best care possible by completing this short survey and mailing it back to us in the postage paid envelope.  

Please fill in the bubble that best describes the quality of your experience at this facility.

Please fix the following input errors:

• dummy

Reception and registration process

Poor Below Average Average Good Excellent

Pre-operative telephone call was informative

Poor Below Average Average Good Excellent

Care provided by the nursing staff before your procedure

Poor Below Average Average Good Excellent

Interaction with the nursing staff in the operating/procedure room

Poor Below Average Average Good Excellent

Interaction with the anesthesia staff

Poor Below Average Average Good Excellent

Care provided by the recovery room staff

Poor Below Average Average Good Excellent

Protection of your privacy

Poor Below Average Average Good Excellent

Cleanliness and appearance of the surgery center

Poor Below Average Average Good Excellent

Your overall preparation, by your physician, for your surgery/procedure

Poor Below Average Average Good Excellent

Your overall confidence in the care provided to you by the staff

Poor Below Average Average Good Excellent

Your overall experience at the surgery center

Poor Below Average Average Good Excellent

Would you recommend the Center to family members or friends?

Yes No

Did you receive verbal and printed discharge instructions?

Yes No

Were the instructions clear?

Yes No

Were directions to the facility adequate?

Yes No

Comments/suggestions:

Date of Service *

Name (Optional)

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I could not have been more comfortable!

Please thank everyone for me, for every time I looked up there was a smile looking back. I could not have been more comfortable. GREAT JOB!!!!"

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