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| Our goal at Stat Anesthesia Specialists, Ltd. is to provide you and/or your family members with the safest, highest quality, state-of-the-art anesthesia services. As part of this continuous effort we need feedback from you, our patients. Please take a few minutes to fill out the following questionnaire. Be assured that your responses will be kept completely confidential. |
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Don't have the time to fill out the form yet? Click here to download a PDF version of this form and fill it later. |
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Excellent |
Above Average |
Average |
Below Average |
Unsatisfactory |
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Anesthesia Provider on Day of Procedure:
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Professionalism
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Courteousness
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Responded to my concerns
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Skills/Abilities
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Explained anesthesia to my satisfaction
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Performed anesthetic to my satisfaction
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Excellent |
Above Average |
Average |
Below Average |
Unsatisfactory |
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Post-Operative Care:
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My immediate post-procedure problems were addressed and
treated effectively (i.e. pain, nausea, and vomiting).
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Discharge instructions were clear and easy to understand.
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Excellent |
Above Average |
Average |
Below Average |
Unsatisfactory |
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General Comments:
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How would you rate your office-based anesthetic/surgical experience
in terms of:
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Convenience
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Comfort
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Privacy
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Addressing any Anxiety issues
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Overall experience
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Have you had an out patient surgical procedure requiring anesthesia in the past?
Yes
No
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If yes, indicate what type of practitioner administered the anesthesia?
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| If yes, how would you compare the care you received from Stat Anesthesia Specialists' Anesthesia Practitioner to that you received from the previous practitioner? |
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better
similar
worse than the previous practitioner.
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Your Name (Optional but helpful)
Again, this information is vital to us in our efforts to continually strive to improve the quality of our anesthesia services. Thank you for taking the time to complete this questionnaire. If you have any concerns or issues relating to your anesthesia care, please feel free to contact us directly at toll free number listed below.
The Management of Stat Anesthesia Specialists, Ltd.
Toll Free Number: 888-782-8847
Fax: 708-394-1007
Email: info@statanesthesia.com
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