Let Us Know How We Did! Survey

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

	Does Not Apply	Poor	Fair	Great
Pre-op Process(es)	Pre-op Process(es) Does Not Apply	Pre-op Process(es) Poor	Pre-op Process(es) Fair	Pre-op Process(es) Great
Completeness of Pre-Op Information	Completeness of Pre-Op Information Does Not Apply	Completeness of Pre-Op Information Poor	Completeness of Pre-Op Information Fair	Completeness of Pre-Op Information Great
Completeness of Post-Op/Discharge Information	Completeness of Post-Op/Discharge Information Does Not Apply	Completeness of Post-Op/Discharge Information Poor	Completeness of Post-Op/Discharge Information Fair	Completeness of Post-Op/Discharge Information Great
Dr. Ken Sinervo, Medical Director/Surgeon	Dr. Ken Sinervo, Medical Director/Surgeon Does Not Apply	Dr. Ken Sinervo, Medical Director/Surgeon Poor	Dr. Ken Sinervo, Medical Director/Surgeon Fair	Dr. Ken Sinervo, Medical Director/Surgeon Great
Dr. Jose Eugenio-Colon, Partner/Surgeon	Dr. Jose Eugenio-Colon, Partner/Surgeon Does Not Apply	Dr. Jose Eugenio-Colon, Partner/Surgeon Poor	Dr. Jose Eugenio-Colon, Partner/Surgeon Fair	Dr. Jose Eugenio-Colon, Partner/Surgeon Great
Victoria Novak, PA-C, Physician Assistant	Victoria Novak, PA-C, Physician Assistant Does Not Apply	Victoria Novak, PA-C, Physician Assistant Poor	Victoria Novak, PA-C, Physician Assistant Fair	Victoria Novak, PA-C, Physician Assistant Great
Kari Mitchell, PA-C, Physician Assistant	Kari Mitchell, PA-C, Physician Assistant Does Not Apply	Kari Mitchell, PA-C, Physician Assistant Poor	Kari Mitchell, PA-C, Physician Assistant Fair	Kari Mitchell, PA-C, Physician Assistant Great
Wendy Winer, RN, BSN, CNOR, RNFA	Wendy Winer, RN, BSN, CNOR, RNFA Does Not Apply	Wendy Winer, RN, BSN, CNOR, RNFA Poor	Wendy Winer, RN, BSN, CNOR, RNFA Fair	Wendy Winer, RN, BSN, CNOR, RNFA Great
Michelle Gallagher, RN, BSN	Michelle Gallagher, RN, BSN Does Not Apply	Michelle Gallagher, RN, BSN Poor	Michelle Gallagher, RN, BSN Fair	Michelle Gallagher, RN, BSN Great
Bianca Rodriguez, CCMA	Bianca Rodriguez, CCMA Does Not Apply	Bianca Rodriguez, CCMA Poor	Bianca Rodriguez, CCMA Fair	Bianca Rodriguez, CCMA Great
Natasha Molina	Natasha Molina Does Not Apply	Natasha Molina Poor	Natasha Molina Fair	Natasha Molina Great
Heather Guidone	Heather Guidone Does Not Apply	Heather Guidone Poor	Heather Guidone Fair	Heather Guidone Great
Cassara Cook	Cassara Cook Does Not Apply	Cassara Cook Poor	Cassara Cook Fair	Cassara Cook Great
Tifany Bostwick	Tifany Bostwick Does Not Apply	Tifany Bostwick Poor	Tifany Bostwick Fair	Tifany Bostwick Great
Cecilia Young	Cecilia Young Does Not Apply	Cecilia Young Poor	Cecilia Young Fair	Cecilia Young Great
Alex Frank	Alex Frank Does Not Apply	Alex Frank Poor	Alex Frank Fair	Alex Frank Great
Arielle Frank	Arielle Frank Does Not Apply	Arielle Frank Poor	Arielle Frank Fair	Arielle Frank Great
Terry Izen	Terry Izen Does Not Apply	Terry Izen Poor	Terry Izen Fair	Terry Izen Great
Shannon McKinney	Shannon McKinney Does Not Apply	Shannon McKinney Poor	Shannon McKinney Fair	Shannon McKinney Great
Patricia Schouten	Patricia Schouten Does Not Apply	Patricia Schouten Poor	Patricia Schouten Fair	Patricia Schouten Great
Miris Obama	Miris Obama Does Not Apply	Miris Obama Poor	Miris Obama Fair	Miris Obama Great
Other staff not mentioned	Other staff not mentioned Does Not Apply	Other staff not mentioned Poor	Other staff not mentioned Fair	Other staff not mentioned Great
Northside Hospital	Northside Hospital Does Not Apply	Northside Hospital Poor	Northside Hospital Fair	Northside Hospital Great
General Follow-Up	General Follow-Up Does Not Apply	General Follow-Up Poor	General Follow-Up Fair	General Follow-Up Great

Does Not Apply

Poor

Fair

Great

Pre-op Process(es)

Pre-op Process(es) Does Not Apply

Pre-op Process(es) Poor

Pre-op Process(es) Fair

Pre-op Process(es) Great

Completeness of Pre-Op Information

Completeness of Pre-Op Information Does Not Apply

Completeness of Pre-Op Information Poor

Completeness of Pre-Op Information Fair

Completeness of Pre-Op Information Great

Completeness of Post-Op/Discharge Information

Completeness of Post-Op/Discharge Information Does Not Apply

Completeness of Post-Op/Discharge Information Poor

Completeness of Post-Op/Discharge Information Fair

Completeness of Post-Op/Discharge Information Great

Dr. Ken Sinervo, Medical Director/Surgeon

Dr. Ken Sinervo, Medical Director/Surgeon Does Not Apply

Dr. Ken Sinervo, Medical Director/Surgeon Poor

Dr. Ken Sinervo, Medical Director/Surgeon Fair

Dr. Ken Sinervo, Medical Director/Surgeon Great

Dr. Jose Eugenio-Colon, Partner/Surgeon

Dr. Jose Eugenio-Colon, Partner/Surgeon Does Not Apply

Dr. Jose Eugenio-Colon, Partner/Surgeon Poor

Dr. Jose Eugenio-Colon, Partner/Surgeon Fair

Dr. Jose Eugenio-Colon, Partner/Surgeon Great

Victoria Novak, PA-C, Physician Assistant

Victoria Novak, PA-C, Physician Assistant Does Not Apply

Victoria Novak, PA-C, Physician Assistant Poor

Victoria Novak, PA-C, Physician Assistant Fair

Victoria Novak, PA-C, Physician Assistant Great

Kari Mitchell, PA-C, Physician Assistant

Kari Mitchell, PA-C, Physician Assistant Does Not Apply

Kari Mitchell, PA-C, Physician Assistant Poor

Kari Mitchell, PA-C, Physician Assistant Fair

Kari Mitchell, PA-C, Physician Assistant Great

Wendy Winer, RN, BSN, CNOR, RNFA

Wendy Winer, RN, BSN, CNOR, RNFA Does Not Apply

Wendy Winer, RN, BSN, CNOR, RNFA Poor

Wendy Winer, RN, BSN, CNOR, RNFA Fair

Wendy Winer, RN, BSN, CNOR, RNFA Great

Michelle Gallagher, RN, BSN

Michelle Gallagher, RN, BSN Does Not Apply

Michelle Gallagher, RN, BSN Poor

Michelle Gallagher, RN, BSN Fair

Michelle Gallagher, RN, BSN Great

Bianca Rodriguez, CCMA

Bianca Rodriguez, CCMA Does Not Apply

Bianca Rodriguez, CCMA Poor

Bianca Rodriguez, CCMA Fair

Bianca Rodriguez, CCMA Great

Natasha Molina

Natasha Molina Does Not Apply

Natasha Molina Poor

Natasha Molina Fair

Natasha Molina Great

Heather Guidone

Heather Guidone Does Not Apply

Heather Guidone Poor

Heather Guidone Fair

Heather Guidone Great

Cassara Cook

Cassara Cook Does Not Apply

Cassara Cook Poor

Cassara Cook Fair

Cassara Cook Great

Tifany Bostwick

Tifany Bostwick Does Not Apply

Tifany Bostwick Poor

Tifany Bostwick Fair

Tifany Bostwick Great

Cecilia Young

Cecilia Young Does Not Apply

Cecilia Young Poor

Cecilia Young Fair

Cecilia Young Great

Alex Frank

Alex Frank Does Not Apply

Alex Frank Poor

Alex Frank Fair

Alex Frank Great

Arielle Frank

Arielle Frank Does Not Apply

Arielle Frank Poor

Arielle Frank Fair

Arielle Frank Great

Terry Izen

Terry Izen Does Not Apply

Terry Izen Poor

Terry Izen Fair

Terry Izen Great

Shannon McKinney

Shannon McKinney Does Not Apply

Shannon McKinney Poor

Shannon McKinney Fair

Shannon McKinney Great

Patricia Schouten

Patricia Schouten Does Not Apply

Patricia Schouten Poor

Patricia Schouten Fair

Patricia Schouten Great

Miris Obama

Miris Obama Does Not Apply

Miris Obama Poor

Miris Obama Fair

Miris Obama Great

Other staff not mentioned

Other staff not mentioned Does Not Apply

Other staff not mentioned Poor

Other staff not mentioned Fair

Other staff not mentioned Great

Northside Hospital

Northside Hospital Does Not Apply

Northside Hospital Poor

Northside Hospital Fair

Northside Hospital Great

General Follow-Up

General Follow-Up Does Not Apply

General Follow-Up Poor

General Follow-Up Fair

General Follow-Up Great

Let Us Know How We Did!

Please Share Your Initial Impressions & Evaluation

Question Title

1. PLEASE ENTER TODAY'S DATE:

Question Title

2. PATIENT NAME:

Question Title

3. DATE OF BIRTH:

Question Title

4. DATE OF CEC SURGERY:

Question Title

5. NAME OF CEC SURGEON:

Question Title

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

Question Title

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?

Question Title

8. PLEASE SELECT ONE ANSWER FOR EACH LINE:

Let Us Know How We Did!

Please Share Your Initial Impressions & Evaluation

Question Title

* 1. PLEASE ENTER TODAY'S DATE:

Question Title

* 2. PATIENT NAME:

Question Title

* 3. DATE OF BIRTH:

Question Title

* 4. DATE OF CEC SURGERY:

Question Title

* 5. NAME OF CEC SURGEON:

Question Title

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

Question Title

* 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?

Question Title

* 8. PLEASE SELECT ONE ANSWER FOR EACH LINE:

1. PLEASE ENTER TODAY'S DATE:

2. PATIENT NAME:

3. DATE OF BIRTH:

4. DATE OF CEC SURGERY:

5. NAME OF CEC SURGEON:

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

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?

8. PLEASE SELECT ONE ANSWER FOR EACH LINE: