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* 1. Which provider did your child see today?

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* 2. Please indicate your level of satisfaction with the following areas related to today's office visit:

  Very Dissatisfied Dissatisfied Neutral Satisfied Very Satisfied N/A
Speaking to a nurse on the phone
Appointment scheduling
Check-in
Wait time
Nursing staff
Amount of time spent with pediatrician
Pediatrician's explanation of diagnosis and treatment plan
Overall visit

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* 3. Did you and your provider talk about the reasons you might want to take a prescribed medication?

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* 4. In the past 6 months, did your provider order a lab, x-ray or referral for your child? (If no, skip the next question)

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* 5. After lab, x-ray or referral was ordered, did our office follow-up with you about those results?

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* 6. How likely are you to recommend our practice to a friend?

  Very Unlikely Unlikely Unsure Likely Very Likely
How likely are you to recommend our practice to a friend?

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* 7. Comments?

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