34 Maple St. Norwalk, CT 06856
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Surgery Survey

Thank you for choosing Norwalk Hospital for your surgery. Norwalk Hospital is a member of the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP). We are gathering information on the outcomes of our patients and how they have been feeling since their surgery.
Cycle Number
*
Case Number
*
Yes
No
*
If you answered NO, you do not need to answer any more questions. If you have answered YES, please answer the following questions.
Yes
No
Yes
No
If no, what was the reason for your visit?
Date(s) of visit(s)
Yes
No
If yes, please explain
Yes
No
Yes
No
If yes, please explain
Date(s) of ED visit or hospitalization
Yes
No
If yes, what type of surgery(ies) did you have?
Date(s) of surgery(ies)