Riverwood Health Care Provider Feedback
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Name of person obtaining phone followup
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Date Of Service
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MM slash DD slash YYYY
Patient First Name
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Patient Last Name
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Phone
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Location
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Choose a location
Mercy Defiance
Mercy Perrysburg
Mercy Sylvania
Fulton County Health Center
Mercy Defiance Departments
Choose a department
Emergency Department
Mercy Perrysburg Departments
Choose a department
Emergency Department
Mercy Sylvania Departments
Choose a department
Emergency Department
Fulton County Health Center
Choose a department
Emergency Department
Please make sure the above selections are correct before proceeding
Are you a patient or visitor?
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Patient
Visitor
Contact Information
First Name
Last Name
Email
Phone
By selecting "I understand", you agree this feedback is not meant for discussion of specific conditions or therapy. If you need further information you will discuss them with your physician. Protection of your privacy is important to us. This is a third party survey. If you are worried about
HIPAA compliance
, either don't include any recognizable personal information, or contact the facility by phone to discuss your experience.
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I understand
Are you Home or in the Emergency Department?
Home
Emergency Department
How long did you wait to see the health care provider?
0-30 minutes
31-60 minutes
>60 minutes
Comments
How do you feel since being seen in the Emergency Department?
Better
Worse
Unchanged
Comments
Did you have any difficulty with the registration process or the registration staff?
No
Yes
Comments
Did the doctor and nurse pay attention to your needs?
Yes
No
Comments
Was your pain managed adequately?
Yes
No
Not applicable
Comments
Were you kept informed about delays in your care?
Yes
No
Not applicable
Comments
Were you cared for appropriately by other departments (lab, x-ray, etc.)?
Yes
No
Not applicable
Comments
Was there something we did really well, or someone that was helpful, we can recognize?
Is there anything we can improve on?
On a scale from 1 to 5, what is the likelihood you would recommend our facility to another person?
1 - Not at all
2
3
4
5 - Very likely
If <5 please let us know why
Did you have any difficulty with the registration process or the registration staff?
No
Yes
Comments
How long did you wait for your test?
0-30 minutes
31-60 minutes
>60 minutes
Comments
Was the waiting room and changing area clean and organized?
Yes
No
Comments
Was the Lab Technician courteous?
Yes
No
Comments
Did the Lab Technician give clear instructions?
Yes
No
Comments
Was there something we did really well, or someone that was helpful, we can recognize?
Is there anything we can improve on?
On a scale from 1 to 5, what is the likelihood you would recommend our facility to another person?
1 - Not at all
2
3
4
5 - Very likely
If <5 please let us know why
Did you have any difficulty with the registration process or the registration staff?
No
Yes
Comments
How long did you wait for your test?
0-30 minutes
31-60 minutes
>60 minutes
Comments
Was the waiting room and changing area clean and organized?
Yes
No
Comments
Was the Radiology Technician courteous?
Yes
No
Comments
Did the Radiology Technician give clear instructions?
Yes
No
Comments
Was there something we did really well, or someone that was helpful, we can recognize?
Is there anything we can improve on?
On a scale from 1 to 5, what is the likelihood you would recommend our facility to another person?
1 - Not at all
2
3
4
5 - Very likely
If <5 please let us know why
This form is not meant to be a replacement for a Press Ganey survey or the like. If you receive any paper survey in the mail, please take the time to fill it out and send it in. Click SUBMIT if you are finished with your responses. If you have more to say, click PREVIOUS.
This form is not meant to be a replacement for a Press Ganey survey. If you receive any paper survey in the mail, please take the time to fill it out and send it in. Click SUBMIT if you are finished. If you have more to add, click PREVIOUS.