Date of procedure: / / Patient Satisfaction Survey Thank you for taking
the time to fill out this survey!
-Cindy Hall, RN, CGRN Administrator
Procedure Facility:

Dear Patient or Family Member,
Jacksonville Center for Endoscopy is committed to providing the highest quality healthcare service to our patients.
We would appreciate your time in completing this survey so that we can better meet your needs.

Was Staff courteous and professional? Yes No
Explanation of Anesthesia was clear? Yes No
Did you receive a followup phone call? Yes No
Would you recommend JCE to others? Yes No
Did you have any safety concerns during your time at our facility that you would like to talk about? Yes No
Was your care handled in a confidential manner? Yes No
Did you experience any unanticipated events following your procedure such as hospitalization or signs of infection? Yes No
Was there one person who was outstanding in their assistance to you? Employee name:
Do you have any suggestions as to how we could have improved your experience with us?


The following information is optional. We assure you it will be kept confidential and used only if we need to speak to you concerning your answers to our survey questions. Thank you for your time.
Name:
Phone: