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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) 


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

Type of Health Coverage:


Medicare
Cigna/Healthsource
Blue Cross/Blue Shield
 
Well Port
TennCare
Self-pay
Other

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

Other: 

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


Depression


Anxiety


Loss of appetite


Weakness


Other


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