LE&RN COE Patient Survey

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Patient Survey

Please tell us your opinion about the service you received from the Center of Excellence you corresponded with or visited. Scores and comments will be shared with the center, but your personal information will remain confidential unless you indicate otherwise.

Name*

Address*

Email*

Confirm Email*

Remain Anonymous*

Are You:*

Self/Patient
Parent/Caregiver of Patient
Healthcare Professional

Is Patient:*

New Patient
Returning Patient

Patient's Age:*

Under 18
18 and Over

RATE YOUR COMMUNICATION WITH THE CENTER:

Which Center of Excellence did you interact with?*

Date of correspondence or appointment*

Did you access the center's website?*

Yes
No
N/A - Does Not Apply

Did you call the center?*

Yes
No
N/A - Does Not Apply

Did you email the center?*

Yes
No
N/A - Does Not Apply

Were your concerns addressed (appt/referral made, questions answered, etc)?*

Yes
No
N/A - Does Not Apply

TELL US ABOUT YOUR VISIT WITH THE CENTER:

Did the patient receive instructions regarding follow-up care?*

Yes
No
N/A - Does Not Apply

Did the patient receive advice on ways to manage their LE/LD?*

Yes
No
N/A - Does Not Apply

Did the patient receive referrals to other LE/LD professionals (if applicable)?

Yes
No
N/A - Does Not Apply

Was the patient given a LE&RN welcome packet?*

Yes
No
N/A - Does Not Apply

Was the patient given information about The International Lymphatic Disease and Lymphedema Patient Registry & Biorepository?*

Yes
No
N/A - Does Not Apply

Was the patient provided information about any LD patient education?*

Yes
No
N/A - Does Not Apply

Was the patient provided information about any LD support groups?*

Yes
No
N/A - Does Not Apply

YOUR OVERALL SATISFACTION WITH:

The Center*

5 - Excellent
4 - Very Good
3 - Good
2 - Fair
1 - Poor
N/A - Does Not Apply

The quality of the patient's medical care*

5 - Excellent
4 - Very Good
3 - Good
2 - Fair
1 - Poor
N/A - Does Not Apply

Would you recommend the Center to others?*

If there is any way the Center can improve their services to you, please tell us about it.

Would you be willing to serve on an Affiliate Board consisting of patients and Center staff dedicated to improving services?*

Thank you for your help.

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