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About
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For Physicians
Contact & Directions
718.884.8660
About
Specialities
For Patients
For Physicians
Contact & Directions
718.884.8660
Patient Satisfaction Survey
Thank you for taking a moment to complete this survey. Your opinion is important to us.
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Date of visit
(Required)
MM slash DD slash YYYY
Medical record #
(Required)
Please check the Service you received
(Required)
Orthopedic Surgery
Pain Management
Gastroentrology
Vascular Surgery
Podiatry
ENT
Opthalmology
Other
Was this your first visit to our ambulatory surgery center?
(Required)
Yes
No
Please rate the ambulatory surgery services you received atPelham Parkway Ambulatory Surgery Center by selecting the response that best describes your experience. If a question does not apply, please skip to the next question.
Ease of access to the facility
(Required)
Excellent
Good
Poor
Timeliness of admitting process
(Required)
Excellent
Good
Poor
Friendliness, courtesy & helpfulness of the receptionist
(Required)
Excellent
Good
Poor
Comfort and attractiveness of the facility
(Required)
Excellent
Good
Poor
Cleanliness of the facility
(Required)
Excellent
Good
Poor
Waiting time before your procedure or surgery began
(Required)
Excellent
Good
Poor
Friendliness and courtesy of the nursing staff
(Required)
Excellent
Good
Poor
Overall quality of care provided by your physician/surgeon
(Required)
Excellent
Good
Poor
Overall quality of care provided by the anesthesiologist
(Required)
Excellent
Good
Poor
Our concern for your privacy
(Required)
Excellent
Good
Poor
Overall rating of the care you received
(Required)
Excellent
Good
Poor
Likelihood of you recommending our center to others
(Required)
Excellent
Good
Poor
What do you like best about our center?
(Required)
What do you like least about our center?
(Required)
How could we improve our service?
(Required)
Your physician’s name (optional)
Your name (optional)