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Patient Satisfactory Survey

We would like to know how you feel about the services we provide so we can make sure we are meeting your need. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous.
Thank you for your time.

 

Instructions

1. Type "anonymous" in the name and email field if you wish to remain unknown

2. Please choose an option based on how well you think we are doing in the following areas below on a scale of 0 to 3; zero being unsatisfactory and 3 being very satisfactory.

 

* Required fields
Name *
E-mail Address *
Ability to get in to be seen:
Hours clinic is open:
Prompt return on calls:
Waiting time in waiting room:
Waiting time in exam room:
Waiting time for tests done in the clinic:
Which provider did you and your child last see? * Dr. Robinson
Rochelle Schultz
How well do you feel that the provider listened to you and your child?
How do you feel about the amount time that provider spent with you and your child?
How well did the provider explain what you wanted to know?
How well do you feel that the provider gave you good advice and treatment for your child?
Friendliness and helpfulness of nursing staff:
Ability of nursing staff to answer your questions:
Neatness and cleanliness of office:
Comfort and safety while waiting:
The likelihood of referring your friends and relatives to us:
Do you consider this clinic your regular source of care for your child(ren)? Yes
No
What do you like best about Lake Area Pediatrics?
What do you like least about Lake Area Pediatrics?
Suggestions for Improvement:

I have read and agree to the Privacy Policy *

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