Name *

Surgery Date ... *

1. How did you hear about Burlington Laser Centre? (Please be specific)

2. What were your motivating factors for choosing Burlington Laser Centre?

3. What was your main concern prior to surgery?

4. What was it that alleviated this concern for you?

5. What improvements should be made related to informing you of expectations, before, during and after surgery?

7. How would you rate your surgical experience? (1 = least favourable) 1 2 3 4 5 6 7 8 9 10

8. In what way(s) could your overall surgical experience have been improved?

9. Would you recommend our facility to others? Yes No

If would no, why?

10. Would you be willing to speak to prospective patients regarding your experience? Yes No

If yes, please inform us of the best time of day and number you could be reached at.

11. Any additional comments to better serve our patients are welcomed.

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Thank you for your time in completing this survey. Your comments are important to our commitment to continuous improvement in serving our patients.