Louisiana Pain Care is committed to providing the best in patient care. We appreciate knowing about your experience with us. Please complete and submit our anonymous patient satisfaction survey. Thank you in advance for your input. Personal Information:Are you: Established Patient New Patient Office Visited:* Monroe Clinic Ruston Clinic ArkLaMiss Surgery Center Advanced Surgery Center of Northern Louisiana Glenwood Medical Center Northern Louisiana Medical Center – Ruston P & S Surgical Hospital St. Francis Medical Center Date of Visit: MM slash DD slash YYYY Provider:* Dr. Ledbetter Dr. Forte Dr. Gordon Andy Austin, FNP, FAAPM Donna Courson, FNP Stephen “Chuck” Stansbury, FNP Mike Lofstrom, FNP Paul Roberts, FNP Bethany Scott, FNP Valerie Boyd, FNP Edie Lemley, FNP How did you hear about us: Dr. Referral/Medical Provider Friend/Family Louisiana Pain Care Website Google, Yahoo, Bing, etc. Billboard Prior Experience Yellow Pages/Phone Book Attorney Radio Other Other Whom may we thank for your referral? (Name & Address):Was there a staff member you would like to recognize? Your ExperienceHow would you rate your overall experience with Louisiana Pain Care? Excellent Very Good Good Fair Poor Please rate the following on a scale 1-5. With 5 being excellent. (5-Excellent 4-Very Good 3-Good 2- Fair 1-Poor)I will likely recommend Louisiana Pain Care to a friend 5 4 3 2 1 Overall, my experience today was 5 4 3 2 1 Overall cleanliness of our office was 5 4 3 2 1 I was able to schedule my appointment within a reasonable amount of time 5 4 3 2 1 The phone staff was professional and friendly 5 4 3 2 1 The check-in staff was efficient and friendly 5 4 3 2 1 Receiving a reminder call or e-mail was helpful 5 4 3 2 1 I received care, concern, & respect from my provider 5 4 3 2 1 I received clear & complete communication from my provider 5 4 3 2 1 Length of time before being seen by provider 5 4 3 2 1 I found the Louisiana Pain Care website to be efficient & helpful 5 4 3 2 1 Would you like to receive statements by e-mail or regular mail? Yes No Please comment on anything regarding our service that we might change to make the patient experience even more positive.Did you experience any problems during recovery? If so, please comment:Information below is optional; however, we would like to acknowledge that you spent the time to give us feedback. May we share your comments with others? Yes No Name First Last PhoneEmail
