Patient Satisfaction Survey

Valued Patient: Our mission is to provide the highest quality care in the most patient friendly manner possible. We believe that you are the best person to tell us how we are doing in achieving it. Please take a moment to tell us how well we are doing. You can fill this form out and submit it online at www.kipsbayendo.com or fax to 212-889-0517.

1. Date of Visit:

2. Have you had a previous Endoscopy/Colonoscopy in our Facility? Yes No

3. Reason for Visit: Upper Endoscopy Colonoscopy EUS

4. Overall understanding and caring of the staff? 3 = Excellent 2 = Good 1 = Poor

5. Overall quality of care provided? 3 = Excellent 2 = Good 1 = Poor

6. Courtesy of the admitting receptionist? 3 = Excellent 2 = Good 1 = Poor

7. Courtesy of the admitting nurse? 3 = Excellent 2 = Good 1 = Poor

8. Courtesy of the discharge nursing staff? 3 = Excellent 2 = Good 1 = Poor

9. Timeliness of admitting process? 3 = Excellent 2 = Good 1 = Poor

10. Information provided in the patient packet? 3 = Excellent 2 = Good 1 = Poor

11. Personal accommodations? 3 = Excellent 2 = Good 1 = Poor

12. Cleanliness of facility? 3 = Excellent 2 = Good 1 = Poor

13. Ease of access to facility? 3 = Excellent 2 = Good 1 = Poor

14. Your satisfaction from time of arrival to discharge? 3 = Excellent 2 = Good 1 = Poor

15. Will you recommend this Center to your friends? and relatives? Yes May be No

16. If "yes", why?

17. If "maybe or no", why?

18. What was the most positive thing about your experience?

19. How could we improve our services?