Patient Survey

Brockville General Hospital

Your views about our Patient Care Services are very important to us. Your experience will help us improve existing services and influence our future plans.


			Poor	1	2	3	4	Excellent

Received all of the required information in advance prior to your visit

Convenience of your appointment time (if applicable)

Your privacy/confidentiality was respected at all times

Comfort and pleasantness of patient area

Courtesy and professionalism of our staff

Explanation of any procedure(s) and education material(s) provided to you

Efficient response to your inquiries or requests

Cleanliness of your room and the hospital in general

Quality of food and service delivery, if hospitalized

Overall impression of the quality of care you received

Ability to navigate easily around the hospital

Please indicate which area(s) you received service at the hospital:			Units

			Other:

			Departments


Date of Visit	# Of Days	Room # (If Inpatient)

Please Provide any additional comments:


Please let us know if you wish to be contacted to discuss:


Please provide your contact information below:
Name:

Phone #:

Address:




Email:


Preferred method of contact:


Thank you for taking the time to provide us with your valuable feedback.

May we share your contact information with the Brockville & District Hospital Foundation?