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Overall Assessment
*
1.
Overall rating of care received during your visit
(Required.)
Excellent
Good
Poor
*
2.
Degree to which staff worked together to care for you
(Required.)
Excellent
Good
Poor
*
3.
Likelihood of your recommendation of our Ambulatory Surgery Center to others
(Required.)
Excellent
Good
Poor
4.
Comments (describe good or bad experience) :
5.
Names of any staff members that may have impressed you during your visit:
6.
If you could change on thing about your visit, what would it be?
7.
What was the best thing about your experience with our surgery center?
8.
Which physician provided care to you this visit?
Dr. Nwofia
Dr. Schneider
Dr. Peace
Dr. Stone
Dr. Traingo-Evans
Dr. Carrero
Dr. Golamco
Dr. Ladson
Other (please specify)
9.
Information (optional):
Name
Date of Service:
Phone Number
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