Cardiac Treatment Feedback Form
Please provide your feedback about your recent cardiac treatment experience to help us improve our services.
Patient Full Name
*
First Name
Last Name
Date of Treatment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Cardiac Treatment Received
*
Please Select
Angioplasty
Bypass Surgery
Pacemaker Implantation
Medication Management
Other
How would you rate the following aspects of your cardiac treatment experience?
*
Rows
Poor
Fair
Good
Very Good
Excellent
Medical staff professionalism
1
2
3
4
5
Explanation of procedures
6
7
8
9
10
Responsiveness to concerns
11
12
13
14
15
Cleanliness of facilities
16
17
18
19
20
Post-treatment care instructions
21
22
23
24
25
Did you experience any side effects during or after your treatment?
*
Yes
No
If yes, please describe the side effects you experienced.
Since your cardiac treatment, how have your symptoms changed?
*
Significantly improved
Somewhat improved
No change
Worsened
Overall, how satisfied are you with your cardiac treatment?
*
1
2
3
4
5
Would you recommend this cardiac treatment center to others?
*
Yes
No
Please share any additional comments or suggestions to help us improve.
Submit Feedback
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