Central Maine Medical Center
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300 Main Street, Lewiston, ME 04240 | 207-795-0111
Central Maine Medical Center - Health Connect

Referral Satisfaction Survey

Regional Referral and Transfer Center Survey

Date of Referral / Transfer :


Time:


Referring Facility:


Referring Provider:


Patient Diagnosis:


Specialty Requested:


1. Overall, how satisfied are you with the services provided by Central Maine Medical Center?
5 - Extremely Satisfied
4 - Very Satisfied
3 - Somewhat Satisfied
2 - Not Very Satisfied
1 - Not at All Satisfied

2. How satisfied are you with the Regional Referral and Transfer Center staff?
5 - Extremely Satisfied
4 - Very Satisfied
3 - Somewhat Satisfied
2 - Not Very Satisfied
1 - Not at All Satisfied

3. How satisfied are you with the Attending Physician to whom you spoke?
5 - Extremely Satisfied
4 - Very Satisfied
3 - Somewhat Satisfied
2 - Not Very Satisfied
1 - Not at All Satisfied

4. Do you feel that from the time you called the Regional Referral and Transfer Center to the time you were connected with the Attending Physician was acceptable?
5 - Extremely Satisfied
4 - Very Satisfied
3 - Somewhat Satisfied
2 - Not Very Satisfied
1 - Not at All Satisfied

5. Please indicate what information would be helpful to you as a referring physician:
Attending physician contact information
Patient follow up
Discharge summary
Operative Notes
Other     
6. How likely are you to recommend Central Maine Medical Center to your colleagues?
5 - Extremely Satisfied
4 - Very Satisfied
3 - Somewhat Satisfied
2 - Not Very Satisfied
1 - Not at All Satisfied

How may we contact you?


Comments:


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