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Patient Survey
Thank you for taking time to complete the patient survey.  Your honest answers will help shape the care of future patients.
Date of ER Visit: (mm/dd/year)
Time of Visit:
Hospital
Physician's Name?
  
How would you rate the quality of the doctor's care that you received in the emergency department?

Excellent  Very Good  Good  Fair  Poor
How would you rate the overall time spent in the emergency department?

Excellent  Very Good  Good  Fair  Poor
How would you rate the overall teamwork between the doctor and the staff?

Excellent  Very Good  Good  Fair  Poor
How would you rate the doctor's explanation of tests, treatment, and discharge instructions?

Excellent  Very Good  Good  Fair  Poor
  
Additional Comments:
 

 


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