• Emergency Room Feedback Survey

• 
  
• Name*
• Phone*

  --
• Email*
• Address (optional)

  Street Address 1

  Street Address 2

  City

  State/Province/Region

  Postal/Zip Code

  Country
• May we contact you, if needed, for further information regarding your visit?*
  Yes No

  If yes, what is your preferred method of contact?
• Date of Visit*
• Time of Visit*

  :AMPM
• Reason for Visit* Select Illness Injury Chest pain, shortness of breath, etc.
• How did you arrive at the emergency room?*

  Ambulance Walk In
• Was your visit a doctor referral?*

  Yes No
• Overall Satisfaction

  	Excellent	Good	Neutral	Poor	Very Poor
  Wait time in lobby
  Cleanliness/comfort of lobby
  Wait time after initial evaluation
  Overall length of visit
  Cleanliness of ER room
  Medical staff professionalism
  Quality of care

• Would you choose our Emergency Room again?*
  Yes No

  If no, why not?
• Would you recommend our Emergency Room to others?

  Yes No
• Please, leave feedback on how we can improve our Emergency Room services?*