Outpatient Surgery Center Patient Feedback Form

Outpatient Surgery Center Patient Feedback Form — Form Fields

This feedback template includes 10 fields. Collect patient feedback on care quality and experience at an outpatient surgical facility. Free to customize and use on ZenBuild.

• Patient Name (optional) (text, optional)
• Type of procedure (dropdown selection, required) — options: Orthopedic, GI/Endoscopy, Eye/Cataract, Plastic Surgery, Oral Surgery, General Surgery, Other
• Pre-Procedure Communication and Preparation (rating, required)
• Staff Care and Attentiveness (rating, required)
• Pain Management (rating, required)
• Recovery Room Care (rating, required)
• Were all your questions answered before the procedure? (multiple choice, required) — options: Yes, thoroughly, Mostly, Some were unanswered, No
• Feedback for the surgical or nursing team (long text, optional)
• Overall Outpatient Surgery Experience (rating, required)
• Would you return to this facility for future procedures? (multiple choice, required) — options: Definitely, Probably, Unlikely, No