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Patient Satisfaction Survey
3.
About Your Child
13%
Thank you for participating in our patient satisfaction survey. We ask that you answer the following questions based on your most recent appointment at our practice.
1.
Is this your child's first visit to our practice?
Yes
No
2.
How long have you brought your child to our practice?
Less than a year
1-3 Years
4-6 Years
+6 Years
3.
What is your child's gender?
Male
Female
4.
(Optional) What type of Insurance does your child have?
Self-Pay
Medicaid
Commercial Insurance
Other
Other (please specify)
5.
What is your child's age?
0-1 Year Old
2-4 Years Old
5-10 Years Old
11-15 Years Old
16-20 Years Old
20+ Years Old
6.
Do you bring other children to our practice?
Yes
No
7.
If you answered Yes to the question above, please indicate how many other children you bring to our practice.
8.
What office do you prefer?
North
South
Centerra
No Preference
Depends on Provider's location
