Patient Satisfaction Survey form

    *PLEASE NOTE:
    → An answer is required for every question unless marked "(optional)".
    → If a multiple-choice question does not apply to you, Click N/A.
    → If a question with a text box does not apply to you, type N/A or n/a.
    Thanks for helping us improve the services we provide!

    _______________________________________________________________
    ►Q1. Likelihood of you recommending our practice to others
    Not LikelyProbablyAbsolutely
    _______________________________________________________________

    Scheduling of Appointments:
    __________________________

    ►Q2. Length of time to reach us for a WELL Appointment
    PoorFairGoodExceptionalN/A

    ►Q3. Courtesy of WELL Appointment scheduler
    PoorFairGoodExceptionalN/A

    ►Q4. Length of time to reach us for a SICK Appointment
    PoorFairGoodExceptionalN/A

    ►Q5. Courtesy of SICK Appointment scheduler
    PoorFairGoodExceptionalN/A

    ►Q6. Appointment time availability to see child in a timely manner
    PoorFairGoodExceptionalN/A

    ►Q7. Helpfulness of SICK Appointment scheduler
    PoorFairGoodExceptionalN/A

    ►Q8. Additional Comments about schedulers

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    Receptionists upon Arrival/Departure:
    ____________________________________

    ►Q9. Your greeting and efficiency upon check-in
    PoorFairGoodExceptionalN/A

    ►Q10. Your greeting and efficiency upon check-out
    PoorFairGoodExceptionalN/A

    ►Q11. Courtesy and personal attention to your needs from the receptionists
    PoorFairGoodExceptionalN/A

    ►Q12. Additional Comments about receptionists

    _______________________________________________________________

    Your Appointment:
    ________________

    ►Q13. Convenience of appointment time
    PoorFairGoodExceptionalN/A

    ►Q14. Pleasantness of wait
    PoorFairGoodExceptionalN/A

    ►Q15. Time waiting in reception area
    PoorFairGoodExceptionalN/A

    ►Q16. Pleasantness and comfort of exam room
    PoorFairGoodExceptionalN/A

    ►Q17. How long did you wait in the exam area?

    ►Q18. What was the time of your appointment?

    _______________________________________________________________

    Your Nurse:
    __________

    ►Q19. Friendliness
    PoorFairGoodExceptionalN/A

    ►Q20. Considerate of your needs/concerns
    PoorFairGoodExceptionalN/A

    ►Q21. Compassionate/Caring
    PoorFairGoodExceptionalN/A

    ►Q22. Additional Comments about your nurse

    _______________________________________________________________

    Your Doctor:
    ___________

    ►Q23. Length of time spent with doctor
    PoorFairGoodExceptionalN/A

    ►Q24. Considerate of your needs/concerns
    PoorFairGoodExceptionalN/A

    ►Q25. Friendliness
    PoorFairGoodExceptionalN/A

    ►Q26. Compassionate/Caring
    PoorFairGoodExceptionalN/A

    ►Q27. Doctor's efforts to include you in decisions concerning treatment options
    PoorFairGoodExceptionalN/A

    ►Q28. Your confidence in this doctor
    PoorFairGoodExceptionalN/A

    ►Q29. Doctor seen today
    Sandra WeidnerRuth SpillermanRebecca EzardRobert CordesTimothy Tam

    ►Q30. Additional Comments about your doctor

    _______________________________________________________________

    Miscellaneous:
    _____________

    ►Q31. Comfort in office
    PoorFairGoodExceptionalN/A

    ►Q32. Cleanliness of office
    PoorFairGoodExceptionalN/A

    ►Q33. Cleanliness of exam room
    PoorFairGoodExceptionalN/A

    ►Q34. Personal attention received
    PoorFairGoodExceptionalN/A

    ►Q35. Parking
    PoorFairGoodExceptionalN/A

    ►Q36. Convenience of office hours
    PoorFairGoodExceptionalN/A

    ►Q37. Our sensitivity to your needs
    PoorFairGoodExceptionalN/A

    ►Q38. Overall cheerfulness of the staff
    PoorFairGoodExceptionalN/A

    ►Q39. Overall rating of care you received
    PoorFairGoodExceptionalN/A

    ►Q40. How did you hear about our office?

    Most convenient time(s) for appointments:
    (You may click more than one choice)
    ►Q41. Morning appointments
    YesNo

    ►Q42. Afternoon appointments
    YesNo

    ►Q43. Evening appointments
    YesNo

    ►Q44. Any other suggestions or additional comments for us to consider

    _______________________________________________________________

    We thank you for your trust and the opportunity to assist you in your child/children's healthcare!

    ►Q45. Name (optional)

    ►Q46. Date (optional)

    _______________________________________________________________

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    ■ Thanks again for your time and effort to help us improve our service to you and all other patients!