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. Reason for Visit:

Upper Endoscopy 
Colonoscopy 
Sigmoidoscopy 
Endoscopic Ultra Sound
Hemorrhoid Banding 

3. Have you had a previous Endoscopy/Colonoscopy/EUS/Sigmoidoscopy in our Facility? Yes No
Instructions: Fill in the box that best describes your experience.
Please rate the following Excellent    Good    Poor
4. Timeliness of admitting process? 3       2       1
5. Ease of access to facility? 3       2       1
6. Courtesy of the admitting receptionist? 3       2       1
7. Courtesy of the billing personnel? 3       2       1
8. Courtesy of the admitting nurse? 3       2       1
9. Courtesy of the recovery room nurse? 3       2       1
10. Courtesy of the Endoscopy Technician? 3       2       1
11. Information provided in the patient packet? 3       2       1
12. Overall understanding and caring of the staff? 3       2       1
13. Personal accommodations? 3       2       1
14. Overall quality of care provided by your physician? 3       2       1
15. Overall quality of care provided by the anesthesiologist? 3       2       1
16. Your satisfaction from time of arrival to discharge? 3       2       1
17. Cleanliness of facility? 3       2       1
18. Will you recommend this Center to your friends and relatives? Yes    May be    No
19. If "yes", why?
20. If "maybe or no", why?
21. What do you like best about our Center?
22. What do you like least about our Center?
23. How could we improve our services?
24. Your Physician's Name (optional)
25. Your Name (optional)