Patient Survey Form


english español 

Thank you for choosing Plainfield Surgery Center for your procedure. We hope that your experience was a positive one. Your comments and suggestions are very important to us. Please fill out this short survey about our service and please leave your contact information if you'd like us to follow-up with you. Thank You!

Patient Information

What is your first name?
What is your last name?
What is your email address?
What is your phone number (xxx-xxx-xxxx)?
Who was the doctor who performed your procedure?  
What type of procedure did you have done?  
What was the date of your surgery(mm/dd/yyyy)?   / /


Strongly Agree Agree Neutral Disagree Strongly Disagree  N/A
You received the information you needed prior to having your procedure with us.
The Front Desk Registration staff was friendly, courteous, and efficient.
The Surgeon spoke with family member(s) after the procedure was performed.
Your discharge instructions were adequate.
The pain medication prescribed for your use after you went home was effective.
Excellent Good Average Fair Poor  N/A
Please rate your overall Surgery Center experience.
Give us your comments. A report of your experience will help us improve our service to you and others. Thank you.