Please Share Your Initial Impressions & Evaluation

Please let us know your initial impressions. Your feedback will be treated as confidential, and it helps us to improve our services for future patients. Should you need assistance, please call 770-913-0001 x120. Please be advised this is a HIPAA-enabled platform. Many thanks! - Center for Endometriosis Care

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* 1. PLEASE ENTER TODAY'S DATE:

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* 2. PATIENT NAME:

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* 3. DATE OF BIRTH:

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* 4. DATE OF CEC SURGERY:

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* 5. NAME OF CEC SURGEON:

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* 6. CURRENT CONTACT INFORMATION (MAIL, PHONE, EMAIL):

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* 7. IF YOU HAVE NOT ALREADY PREVIOUSLY CONTACTED US TO FOLLOW-UP ON ANY AREAS OF CONCERN, DO YOU WISH TO BE CONTACTED REGARDING THE FEEDBACK YOU ARE PROVIDING?

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* 8. PLEASE SELECT ONE ANSWER FOR EACH LINE:

  Does Not Apply Poor Fair Great
Pre-op Process(es)
Completeness of Pre-Op Information
Completeness of Post-Op/Discharge Information
Dr. Ken Sinervo, Medical Director/Surgeon
Dr. Jose Eugenio-Colon, Surgeon
Wendy Winer, RN, BSN, CNOR, RNFA, Surgical Assistant
Other Surgical Assistant
Victoria Novak, PA-C, Physician Assistant
Michelle Gallagher, RN, BSN, Nursing/Medical
Britney Massey, BS, Nursing/Medical
Anna Dorris, Practice Manager
Terry Izen, Billing Manager
Heather Guidone, BCPA, Surgical Program Director
Jean Williams, Surgical Coordinator
Tifany Bostwick, Surgical Coordinator
Natasha Molina, Surgical Coordinator
Alex Frank, MA/Administrator
Arielle Frank, Administrator
Shannon McKinney, Administrator
Cecilia Young, Insurance Expert
Northside Hospital
General Follow-Up
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