{"id":802,"date":"2026-03-18T21:04:37","date_gmt":"2026-03-18T21:04:37","guid":{"rendered":"https:\/\/reviveorthopedics.com\/surgerycenter\/?page_id=802"},"modified":"2026-03-18T21:35:41","modified_gmt":"2026-03-18T21:35:41","slug":"patient-survey","status":"publish","type":"page","link":"https:\/\/reviveorthopedics.com\/surgerycenter\/contact-us\/patient-survey\/","title":{"rendered":"Patient Survey"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"802\" class=\"elementor elementor-802\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-40d1e57 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"40d1e57\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-12b05d9\" data-id=\"12b05d9\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-54c8a61 elementor-align-center elementor-widget elementor-widget-button\" data-id=\"54c8a61\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/reviveorthopedics.com\/surgerycenter\/wp-content\/uploads\/sites\/5\/2026\/03\/ASC-Pt-Satisfaction-Survery.pdf\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Click Here For Printable PDF<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1a96298 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"1a96298\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-90de944\" data-id=\"90de944\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-026c079 eael-gravity-form-button-custom elementor-widget elementor-widget-eael-gravity-form\" 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Survey<\/h2>\n                            <p class='gform_description'><b>Thank you for choosing our Ambulatory Surgery Center for your care.<\/b>\r\n<br>\r\nYour feedback helps us improve our services. Please take a few minutes to complete this survey. \r\nAll responses are confidential.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/surgerycenter\/wp-json\/wp\/v2\/pages\/802' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_1_18\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_18'>What date did you visit our surgical facility?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_18' id='input_1_18' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_18_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_18_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_18' class='gform_hidden' value='https:\/\/reviveorthopedics.com\/surgerycenter\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Please rate the following aspects of your experience:<\/h3><\/div><fieldset id=\"field_1_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ease of scheduling your procedure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_42'><div class='gchoice gchoice_1_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Excellent'  id='choice_1_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_1' id='label_1_42_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.2' type='checkbox'  value='Good'  id='choice_1_42_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_2' id='label_1_42_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.3' type='checkbox'  value='Fair'  id='choice_1_42_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_3' id='label_1_42_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_42_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.4' type='checkbox'  value='Poor'  id='choice_1_42_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_42_4' id='label_1_42_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Courtesy of front desk staff<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_43'><div class='gchoice gchoice_1_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Excellent'  id='choice_1_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_1' id='label_1_43_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.2' type='checkbox'  value='Good'  id='choice_1_43_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_2' id='label_1_43_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.3' type='checkbox'  value='Fair'  id='choice_1_43_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_3' id='label_1_43_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_43_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.4' type='checkbox'  value='Poor'  id='choice_1_43_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_43_4' id='label_1_43_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Clarity of preoperative instructions<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_44'><div class='gchoice gchoice_1_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Excellent'  id='choice_1_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_1' id='label_1_44_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.2' type='checkbox'  value='Good'  id='choice_1_44_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_2' id='label_1_44_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.3' type='checkbox'  value='Fair'  id='choice_1_44_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_3' id='label_1_44_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_44_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.4' type='checkbox'  value='Poor'  id='choice_1_44_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_44_4' id='label_1_44_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Wait time before procedure<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_45'><div class='gchoice gchoice_1_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Excellent'  id='choice_1_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.2' type='checkbox'  value='Good'  id='choice_1_45_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_2' id='label_1_45_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.3' type='checkbox'  value='Fair'  id='choice_1_45_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_3' id='label_1_45_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_45_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.4' type='checkbox'  value='Poor'  id='choice_1_45_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_45_4' id='label_1_45_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cleanliness of the facility<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_46'><div class='gchoice gchoice_1_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Excellent'  id='choice_1_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_46_1' id='label_1_46_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_46_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.2' type='checkbox'  value='Good'  id='choice_1_46_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_46_2' id='label_1_46_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_46_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.3' type='checkbox'  value='Fair'  id='choice_1_46_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_46_3' id='label_1_46_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_46_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.4' type='checkbox'  value='Poor'  id='choice_1_46_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_46_4' id='label_1_46_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Friendliness of nursing staff<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_47'><div class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Excellent'  id='choice_1_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_47_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.2' type='checkbox'  value='Good'  id='choice_1_47_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_2' id='label_1_47_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_47_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.3' type='checkbox'  value='Fair'  id='choice_1_47_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_3' id='label_1_47_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_47_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.4' type='checkbox'  value='Poor'  id='choice_1_47_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_47_4' id='label_1_47_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Communication from your surgeon<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_48'><div class='gchoice gchoice_1_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Excellent'  id='choice_1_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_48_1' id='label_1_48_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_48_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.2' type='checkbox'  value='Good'  id='choice_1_48_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_48_2' id='label_1_48_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_48_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.3' type='checkbox'  value='Fair'  id='choice_1_48_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_48_3' id='label_1_48_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_48_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.4' type='checkbox'  value='Poor'  id='choice_1_48_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_48_4' id='label_1_48_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Comfort during your stay<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_49'><div class='gchoice gchoice_1_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Excellent'  id='choice_1_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_49_1' id='label_1_49_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_49_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.2' type='checkbox'  value='Good'  id='choice_1_49_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_49_2' id='label_1_49_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_49_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.3' type='checkbox'  value='Fair'  id='choice_1_49_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_49_3' id='label_1_49_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_49_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.4' type='checkbox'  value='Poor'  id='choice_1_49_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_49_4' id='label_1_49_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Discharge instructions clarity<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_50'><div class='gchoice gchoice_1_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Excellent'  id='choice_1_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_50_1' id='label_1_50_1' class='gform-field-label gform-field-label--type-inline'>Excellent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='Good'  id='choice_1_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_50_2' id='label_1_50_2' class='gform-field-label gform-field-label--type-inline'>Good<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Fair'  id='choice_1_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_50_3' id='label_1_50_3' class='gform-field-label gform-field-label--type-inline'>Fair<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_50_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.4' type='checkbox'  value='Poor'  id='choice_1_50_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_50_4' id='label_1_50_4' class='gform-field-label gform-field-label--type-inline'>Poor<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Please indicate your agreement with the statements below:<\/h3><\/div><fieldset id=\"field_1_34\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Staff treated me with courtesy and respect.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_34'><div class='gchoice gchoice_1_34_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.1' type='checkbox'  value='Strongly Agree'  id='choice_1_34_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_1' id='label_1_34_1' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.2' type='checkbox'  value='Agree'  id='choice_1_34_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_2' id='label_1_34_2' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.3' type='checkbox'  value='Neutral'  id='choice_1_34_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_3' id='label_1_34_3' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.4' type='checkbox'  value='Disagree'  id='choice_1_34_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_4' id='label_1_34_4' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_34_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_34.5' type='checkbox'  value='Strongly Disagree'  id='choice_1_34_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_34_5' id='label_1_34_5' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_35\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >My questions were answered thoroughly.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_35'><div class='gchoice gchoice_1_35_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.1' type='checkbox'  value='Strongly Agree'  id='choice_1_35_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_35_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.2' type='checkbox'  value='Agree'  id='choice_1_35_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_2' id='label_1_35_2' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_35_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.3' type='checkbox'  value='Neutral'  id='choice_1_35_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_3' id='label_1_35_3' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_35_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.4' type='checkbox'  value='Disagree'  id='choice_1_35_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_4' id='label_1_35_4' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_35_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_35.5' type='checkbox'  value='Strongly Disagree'  id='choice_1_35_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_35_5' id='label_1_35_5' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_36\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gf_list_5col gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >I felt safe during my visit.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_36'><div class='gchoice gchoice_1_36_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.1' type='checkbox'  value='Strongly Agree'  id='choice_1_36_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_1' id='label_1_36_1' class='gform-field-label gform-field-label--type-inline'>Strongly Agree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_36_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.2' type='checkbox'  value='Agree'  id='choice_1_36_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_2' id='label_1_36_2' class='gform-field-label gform-field-label--type-inline'>Agree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_36_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.3' type='checkbox'  value='Neutral'  id='choice_1_36_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_3' id='label_1_36_3' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_36_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.4' type='checkbox'  value='Disagree'  id='choice_1_36_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_4' id='label_1_36_4' class='gform-field-label gform-field-label--type-inline'>Disagree<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_36_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_36.5' type='checkbox'  value='Strongly Disagree'  id='choice_1_36_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_36_5' id='label_1_36_5' class='gform-field-label gform-field-label--type-inline'>Strongly Disagree<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_20\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How likely are you to recommend our center to family or friends?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_20'><div class='gchoice gchoice_1_20_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.1' type='checkbox'  value='gsurvey987fb8f52'  id='choice_1_20_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_1' id='label_1_20_1' class='gform-field-label gform-field-label--type-inline'>Very Likely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.2' type='checkbox'  value='gsurvey9671d0151'  id='choice_1_20_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_2' id='label_1_20_2' class='gform-field-label gform-field-label--type-inline'>Likely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.3' type='checkbox'  value='gsurvey98963f804'  id='choice_1_20_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_3' id='label_1_20_3' class='gform-field-label gform-field-label--type-inline'>Not Sure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.4' type='checkbox'  value='gsurvey9f51f117f'  id='choice_1_20_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_4' id='label_1_20_4' class='gform-field-label gform-field-label--type-inline'>Unlikely<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_20_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_20.5' type='checkbox'  value='gsurvey915ff13f4'  id='choice_1_20_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_20_5' id='label_1_20_5' class='gform-field-label gform-field-label--type-inline'>Very Unlikely<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_9\" class=\"gfield gfield--type-survey gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >How satisfied were you with your overall experience?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_9'><div class='gchoice gchoice_1_9_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.1' type='checkbox'  value='gsurvey987fb8f52'  id='choice_1_9_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>Very Satisfied<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.2' type='checkbox'  value='gsurvey9671d0151'  id='choice_1_9_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_2' id='label_1_9_2' class='gform-field-label gform-field-label--type-inline'>Satisfied<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.3' type='checkbox'  value='gsurvey98963f804'  id='choice_1_9_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_3' id='label_1_9_3' class='gform-field-label gform-field-label--type-inline'>Neutral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.4' type='checkbox'  value='gsurvey9f51f117f'  id='choice_1_9_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_4' id='label_1_9_4' class='gform-field-label gform-field-label--type-inline'>Dissatisfied<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_1_9_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_9.5' type='checkbox'  value='gsurvey915ff13f4'  id='choice_1_9_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_9_5' id='label_1_9_5' class='gform-field-label gform-field-label--type-inline'>Very Dissatisfied<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-survey gfield--input-type-textarea field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_12'>What Did We Do Well?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_12' id='input_1_12' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-survey gfield--input-type-textarea gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_21'>What Can We Improve?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_21' id='input_1_21' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_25'>Would you like us to contact you regarding your care?<\/label><div class='ginput_container ginput_container_select'><select name='input_25' id='input_1_25' class='large gfield_select'     aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_1'>\n                            \n                            <span id='input_1_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_1_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_1_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_1_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_1_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_1_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_23'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='qTjY5Na36NbbAaDMC7EPHHvRpeoO6Zw4\/\/6vmDN9meE9zXixN5gD40I98lwwL4+2WEbzeAARJyTDnztCxj9YDzcwMD8aIX4hr9S5Q54gcSM85ec=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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