Interventional Spine and Pain Management - Atlanta Spine Treatment

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Patient Survey

Was your ID asked for before you received your armband at check in? Yes No

Was your armband checked when you met a new staff member? Yes No

While in the facility, do you feel your privacy was protected? Yes No

Did you witness staff members washing their hands? Yes No

Did anything distract you from understanding the staffs actions and intentions? Yes No
If yes, please list:

Did you notice the environment to be clean and organized? Yes No

Were you able to alert the staff easily of a problem, need, or concern? Yes No

Do you feel your needs were properly attended to by the staff? Yes No

Is there anyone who was particularly helpful?

Did you notice any safety hazards or concerns? Yes No If yes, please list:

Did you understand the pre-procedure instructions before coming in for your procedure? Yes No

Did the physician review your medical history with you prior to your procedure? Yes No

Were you provided clear information about your procedure? Yes No

Did you understand the information provided? Yes No

Do you feel you were given enough time to ask questions? Yes No

Do you feel you understood the risks associated with the procedure? Yes No

Did the physician review the treatment plan with you today? Yes No

Did the physician review the treatment plan with you today? Clinic: Yes No Pre-Op: Yes No

Did you receive a list of your medications at your last procedure? Yes No

After being contacted by our office, were you offered an appointment within a few days? Yes No

How long did it take for your call to be returned? < 1 day 1-2 days > 2 days

If referred by a physician, how many days did it take for our office to contact you? < 1 day 1-2 days > 2 days

Did you or do you understand the waiting period between your procedures? Yes No

How long did you have to wait until you were taken back into the OR? < 15 mins. 15-30 mins. > 30 mins.

During your visit for follow-up or new patient consultation, how long did you wait until see a provider? < 15 mins. 15-30 mins. > 30 mins.

Please feel free to express any specific compliments or concerns in the space below: