Patient Survey

Patient Survey

*(Fields marked with asterisk are optional, as this is a confidential survey, but you may give your name, address, and/or e-mail address for a response.)

Give numbered responses in degree of agreement: 5-Fully agree, 4-Somewhat agree, 3-Neutral, 2-Somewhat disagree, 1-Fully disagree.

FOR EMERGENCY ROOM PATIENTS:	5	4	3	2	1
I was seen as quickly as possible
I received appropriate care for my needs
The hospital staff treated me well
The doctor treated me well
I would come to the ER again if I needed to
I received the highest possible quality care

What I liked best:

What I liked least:

*Request response:

*Name:
*E-mail:
*Address:
*City:
*State:
*ZIP:

*(Fields marked with asterisk are optional, as this is a confidential survey, but you may give your name, address, and/or e-mail address for a response.)

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