Please share your experiences with us

Your impressions of our practice are very important to us. We at the Alliance of Cardiac, Thoracic & Vascular Surgeons (ACTV) thank you for taking a few moments to evaluate our performance.

The quality of the relationship between physician and patient is one of the most personal and most important there can be. This survey is intended to provide information that will help improve the quality of patient care provided by our physicians, nurses and office staff.

In recent weeks you received surgical services from our practice. We ask that you take a few moments to complete this evaluation of the care you received. Please feel comfortable being totally honest in your evaluation. You are not required to provide your name.

After completing the questions, click the submit button. Thank you!  

What is the name of the surgeon who was primarily responsible for your care?

What is the name of the physician who referred you to the surgeon above?

Please describe yourself:
(or the patient if you are completing this survey on behalf of someone else) 

Male    Female
0-6 years            31-45 years
7-15 years          46-65 years
16-30 years        Over 75 years    

Type of Health Coverage:

Blue Cross/Blue Shield
Well Port

Evaluate each of your experiences with our office as described below

Please rate...

Excellent Very Good Good Fair Poor

Ease in reaching ACTV by telephone

Difficulty (or wait) in making an appointment

Convenience of office hours

Courtesy of our staff

Ease of our registration process

Comfort of our waiting areas

Respect for your privacy

Cleanliness of the office

Ease in getting questions answered

Availability of parking

Which office did you visit?

Memorial Plaza (Main Office)
Chattanooga Heart Institute
Diagnostic Center (Parkridge)

Erlanger Plaza
Hutcheson Medical Center

About your physician

Please rate...

Excellent Very Good Good Fair Poor
Physician's promptness in seeing you before surgery (time you waited to see surgeon after referral

Physician's promptness in seeing you in the office after surgery

Amount of time physician spent talking with you

Physician's willingness to answer your questions

Physician's personal manner (courtesy, respect, communication, friendliness)

About your nurse

Please rate...

Excellent Very Good Good Fair Poor

Nurse's responsiveness to your needs

Nurse's ability to answer your questions

Professionalism of your nurse

Nurse's personal manner (courtesy, respect, communication, friendliness)

What is the name of your nurse?

After your surgery

Please rate...

Excellent Very Good Good Fair Poor

Ease of insurance and billing procedures

Accuracy of billing

Helpfulness of take-home patient inforation you received (Literature that explains your illness or helps you care for yourself/patient at home)

Response to after hours calls for help or information

About the hospital

Please rate...

Excellent Very Good Good Fair Poor
Quality of hospital staff

Comfort of the hospital

Overall impression of the hospital

Which hospital were you in?

Memorial Hospital
Parkridge Hospital

Erlanger Medical Center
Hutcheson Medical Center


Overall impressions

Please rate...

Excellent Very Good Good Fair Poor

Your overall satisfaction with the services of ACTV

The outcome of your medical care

Your attitude about the future of your health

Likelihood you would recommend your surgeon to others

Continuing symptoms

Indicate the current status of any of the
continuing symptoms below
Not a problem Getting better About the same Getting worse

Irregular heartbeat

Shortness of breath

Pain in chest incision

Pain in leg incision



Loss of appetite



We value your comments and suggestions

What did you like best about your care?



What are the most important things we can do to improve our services?


This section is optional
If you would like for someone to contact you concerning your experiences,
please type your contact information in the space below.

Your name

Daytime phone:

Evening phone:

Thank you