Pioneer Valley Surgicenter

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To help us improve our performance please complete this optional customer survey. Thank you in advance for your cooperation.

Date of Surgery:	Physician:

Were you treated in a courteous, pleasent and professional manner?		Yes No
Do you feel that your Pre-Op and Post-Op instructions prior to surgery was adequate?		Yes No
Do you feel the Surgical Center personnel were interested in you as a person?		Yes No
Were you comfortable with the lighting, temperature, and general surroundings?		Yes No
Do you feel your seperation from your family member or friend was minimal?		Yes No
Were written instructions given to you and reviewed with you before leaving the Center?		Yes No
How would you rate your overall experience?		Excellent Good Fair Poor

Are there any ways that the staff (office, nursing, surgeon, and anesthesiologist) could have improved your experience the day of surgery?

Please list any general comments or suggestions:

If you prefer, you may download the form to print, e-mail, or have for your records by clicking here. NOTE: You must have Adobe Acrobat reader installed. If you don't, you may download it for free by clicking here.