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Dosher Memorial Hospital

Patient Satisfaction Survey

Thank you for filling out Dosher Memorial Hospital's Online Patient Satisfaction Survey.

Please take a few moments to complete this short survey, and share your impression of your patient experience at Dosher with us. Your input will be very valuable to us as we continually strive to provide the best possible care for the patients we serve.
* Patient Name
Please enter the patient's first and last name.
* Patient Age
Enter the patient's age.
* Address
Enter the patient's address.
* City
Enter the city where the patient lives.
* State
Enter the state where the patient lives. For example NC.
* Zipcode
Enter the patient's Zip Code. For example 28461.
* Phone Number or Email Address
Enter the patient's phone number or email address.
* Date of Service
The date the patient received service at Dosher Hospital. For example 5/7/2010
* Type of Service
Please select whether this was an Inpatient or Outpatient Service
Inpatient Service     Outpatient Service    
* Department
Please choose which department provided the service.
If you indicated "Other" above, please describe the service you received.
* Overall Satisfaction Rating with Department or Service
On a scale of 1 to 5 (with 1 being the worst and 5 being the best) how would you rate your overall patient experience with this department or service?
1     2     3     4     5    
  Emergency Department Physician Satisfaction Rating
If you were seen by an Emergency Department physician, please rate your ED physician experience on a scale of 1 to 5 (with 1 being the worst and 5 being the best).
1     2     3     4     5    
  Additional Comments
Please add any additional comments about your service, or suggestions for improvement in this department or the hospital.