Weight Loss Surgery Center of Hampton Roads

Patient Survey Form

A. PATIENT INFORMATION

Please take a moment to answer the survey. Your feedback will greatly help us in implementing improvements in our customer care standards. The result of this survey will remain confidential and the completed form will only be used internally for the purpose of serving you better. Thank you for your time.

Patient Name

Email

Address

Contact Number

Appointment Date

B. OFFICE


B1. Did you like the atmosphere and/or decor of our office? Yes No
If not, please explain why.

B2. Was there any aspect of our facility that you were particularly satisfied with? Yes No
If yes, please explain why.

B3. Was there any aspect of our facility that you were unsatisfied with? Yes No
If yes, please explain why.

Please give your comments on how we can further improve this aspect of our practice.

Please give our office/facilities a rating from 1 for poor to 10 for excellent.

RATING :::	Poor			Average				Excellent
	1	2	3	4	5	6	7	8	9	10
Clean
Spacious
Well-Lighted
Comfortable
Well-Arranged

C. STAFF


C1. Did we make you feel welcome when you came into our office? Yes No
If we were not able to do so, please explain why.

C2. Did we serve you in a friendly manner when you had questions? Yes No
If we were not able to do so, please explain why.

C3. Was there a staff member that was particularly helpful to you during your visit? Yes No
If yes, please tell us about him/her and how she helped you.

C4. Was there a particular staff member that needs to improve some aspects of his/her service? Yes No
If yes, please tell us about him/her and how she can improve his/her service.

Please give our staff's performance a rating from 1 for poor to 10 for excellent.

RATING :::	Poor			Average				Excellent
	1	2	3	4	5	6	7	8	9	10
Friendly
Attentive
Patient
Explains Clearly
Properly Attired

D. APPOINTMENT

D1. Did we remind you of your appointment a few days ahead?
Yes No

D2. Did you have to wait a long time past your appointment time to be seated? Yes No
If you did, for how long? 15 to 30 minutes 30 to 45 minutes over 45 minutes

Please give your comments on how we can further improve this aspect of our service.

Please give your rating for the efficiency of this service. From 1 for poor to 10 for excellent.

Poor			Average				Excellent
1	2	3	4	5	6	7	8	9	10

E. FINANCE

E1. Did we give you a thorough understanding of the financial options available to you?
Yes No

E2. Were your financial matters handled in a timely and satisfactory manner? Yes No
If no, please give suggestions on how we can further improve this aspect of our service.

Please give this aspect of our practice a rating from 1 for poor to 10 for excellent.

RATING :::	Poor			Average				Excellent
	1	2	3	4	5	6	7	8	9	10
Easy to Follow
On-Time
Efficient

F. SERVICES

F1. What type of services did you request from our office?
Gastric Bypass Surgery Lap Band Surgery Metabolic Testing
Dietary Counseling Others*

*Please specify

F2. Did we discuss with you all available treatment options during your consultation?
Yes No

F3. Did we discuss with you the details of the procedure prior to your treatment?
Yes No

F4. Did you encounter any problem, or do you have any complaints regarding your treatment? Yes No
If yes, please tell us about it.

Please give our services a rating from 1 for poor to 10 for excellent.

RATING :::	Poor			Average				Excellent
	1	2	3	4	5	6	7	8	9	10
Clearly Explained Procedure
Properly Attired Personnel
Actual Treatment/Procedure
Hygienic Measures (face masks, rubber gloves, etc.)

G. GENERAL

G1. What other information would you like to be made available to you during your visit to our office and/or on our website? Please list them down or write down a topic that is relevant for you to learn about. (Example: Infection control, pain management, etc.)

G3. Would you recommend our office to your family and friends?
Yes No

Please give our practice an overall rating from 1 for poor to 10 for excellent.

Poor			Average				Excellent
1	2	3	4	5	6	7	8	9	10

Thank you for taking the time to complete our survey.