Surf Pediatrics and Medicine Survey

Question Title

* 1. Please rate our scheduling.

	Excellent	Good	Fair	Poor
For a sick/problem visit: Able to get an appointment within a reasonable amount of time.	For a sick/problem visit: Able to get an appointment within a reasonable amount of time. Excellent	For a sick/problem visit: Able to get an appointment within a reasonable amount of time. Good	For a sick/problem visit: Able to get an appointment within a reasonable amount of time. Fair	For a sick/problem visit: Able to get an appointment within a reasonable amount of time. Poor
For a physical/well visit: Able to get an appointment within a reasonable amount of time.	For a physical/well visit: Able to get an appointment within a reasonable amount of time. Excellent	For a physical/well visit: Able to get an appointment within a reasonable amount of time. Good	For a physical/well visit: Able to get an appointment within a reasonable amount of time. Fair	For a physical/well visit: Able to get an appointment within a reasonable amount of time. Poor
The convenience of our hours and available appointment times.	The convenience of our hours and available appointment times. Excellent	The convenience of our hours and available appointment times. Good	The convenience of our hours and available appointment times. Fair	The convenience of our hours and available appointment times. Poor
The ability to see the provider of your choice.	The ability to see the provider of your choice. Excellent	The ability to see the provider of your choice. Good	The ability to see the provider of your choice. Fair	The ability to see the provider of your choice. Poor
The wait time to see your nurse was reasonable.	The wait time to see your nurse was reasonable. Excellent	The wait time to see your nurse was reasonable. Good	The wait time to see your nurse was reasonable. Fair	The wait time to see your nurse was reasonable. Poor
The wait time to see your provider was reasonable.	The wait time to see your provider was reasonable. Excellent	The wait time to see your provider was reasonable. Good	The wait time to see your provider was reasonable. Fair	The wait time to see your provider was reasonable. Poor

Other (please specify)

Question Title

* 2. Please rate your wait time in office.

	5-15 Minutes	20-30 Minutes	35-45 Minutes	Over 50 Minutes
Wait time to see nurse.	Wait time to see nurse. 5-15 Minutes	Wait time to see nurse. 20-30 Minutes	Wait time to see nurse. 35-45 Minutes	Wait time to see nurse. Over 50 Minutes
Wait time to see a provider.	Wait time to see a provider. 5-15 Minutes	Wait time to see a provider. 20-30 Minutes	Wait time to see a provider. 35-45 Minutes	Wait time to see a provider. Over 50 Minutes

Question Title

* 3. Please rate facilities.

	Excellent	Good	Fair	Poor
The cleanliness and comfort of the office itself.	The cleanliness and comfort of the office itself. Excellent	The cleanliness and comfort of the office itself. Good	The cleanliness and comfort of the office itself. Fair	The cleanliness and comfort of the office itself. Poor
Our parking facilities.	Our parking facilities. Excellent	Our parking facilities. Good	Our parking facilities. Fair	Our parking facilities. Poor
Availability of adult reading materials.	Availability of adult reading materials. Excellent	Availability of adult reading materials. Good	Availability of adult reading materials. Fair	Availability of adult reading materials. Poor
Availability of children's books or toys.	Availability of children's books or toys. Excellent	Availability of children's books or toys. Good	Availability of children's books or toys. Fair	Availability of children's books or toys. Poor

Other (please specify)

Question Title

* 4. Please rate the courtesy, helpfulness, and knowledge of our staff.

	Excellent	Good	Fair	Poor
Receptionist	Receptionist Excellent	Receptionist Good	Receptionist Fair	Receptionist Poor
Schedulers	Schedulers Excellent	Schedulers Good	Schedulers Fair	Schedulers Poor
Nurse	Nurse Excellent	Nurse Good	Nurse Fair	Nurse Poor
Billing	Billing Excellent	Billing Good	Billing Fair	Billing Poor

Other (please specify)

Question Title

* 5. Please rate our communication and coordination of care.

	Excellent	Good	Fair	Poor
Your ease in reaching our office by phone.	Your ease in reaching our office by phone. Excellent	Your ease in reaching our office by phone. Good	Your ease in reaching our office by phone. Fair	Your ease in reaching our office by phone. Poor
If your call required a return call from a nurse, the call was returned in a reasonable amount of time.	If your call required a return call from a nurse, the call was returned in a reasonable amount of time. Excellent	If your call required a return call from a nurse, the call was returned in a reasonable amount of time. Good	If your call required a return call from a nurse, the call was returned in a reasonable amount of time. Fair	If your call required a return call from a nurse, the call was returned in a reasonable amount of time. Poor
If your call required a return call from a provider, the call was returned in a reasonable amount of time	If your call required a return call from a provider, the call was returned in a reasonable amount of time Excellent	If your call required a return call from a provider, the call was returned in a reasonable amount of time Good	If your call required a return call from a provider, the call was returned in a reasonable amount of time Fair	If your call required a return call from a provider, the call was returned in a reasonable amount of time Poor
Quality of information of medical advice provided by phone.	Quality of information of medical advice provided by phone. Excellent	Quality of information of medical advice provided by phone. Good	Quality of information of medical advice provided by phone. Fair	Quality of information of medical advice provided by phone. Poor
Our timeliness in completing any forms, paperwork requests, or specialist referrals.	Our timeliness in completing any forms, paperwork requests, or specialist referrals. Excellent	Our timeliness in completing any forms, paperwork requests, or specialist referrals. Good	Our timeliness in completing any forms, paperwork requests, or specialist referrals. Fair	Our timeliness in completing any forms, paperwork requests, or specialist referrals. Poor
Keeping you informed of any delays with your appointment.	Keeping you informed of any delays with your appointment. Excellent	Keeping you informed of any delays with your appointment. Good	Keeping you informed of any delays with your appointment. Fair	Keeping you informed of any delays with your appointment. Poor
Timely notification of test, lab, and/or imaging results.	Timely notification of test, lab, and/or imaging results. Excellent	Timely notification of test, lab, and/or imaging results. Good	Timely notification of test, lab, and/or imaging results. Fair	Timely notification of test, lab, and/or imaging results. Poor

Other (please specify)

Question Title

* 6. Pleas rate your visit with your provider.

	Excellent	Good	Fair	Poor
Courtesy of the provider.	Courtesy of the provider. Excellent	Courtesy of the provider. Good	Courtesy of the provider. Fair	Courtesy of the provider. Poor
Provider's patience and interest in your reason for visit.	Provider's patience and interest in your reason for visit. Excellent	Provider's patience and interest in your reason for visit. Good	Provider's patience and interest in your reason for visit. Fair	Provider's patience and interest in your reason for visit. Poor
Explanations of diagnosis and treatment options.	Explanations of diagnosis and treatment options. Excellent	Explanations of diagnosis and treatment options. Good	Explanations of diagnosis and treatment options. Fair	Explanations of diagnosis and treatment options. Poor
Your overall satisfaction with the medical care you received.	Your overall satisfaction with the medical care you received. Excellent	Your overall satisfaction with the medical care you received. Good	Your overall satisfaction with the medical care you received. Fair	Your overall satisfaction with the medical care you received. Poor
Assistance and support for making changes in health habits and making health care decisions.	Assistance and support for making changes in health habits and making health care decisions. Excellent	Assistance and support for making changes in health habits and making health care decisions. Good	Assistance and support for making changes in health habits and making health care decisions. Fair	Assistance and support for making changes in health habits and making health care decisions. Poor

Other (please specify)

Question Title

* 7. General Office Questions.

	Yes	No
Have you used our website for patient services?	Have you used our website for patient services? Yes	Have you used our website for patient services? No	Have you used our website for patient services?	Have you used our website for patient services?
Have you used our after-hours call service?	Have you used our after-hours call service? Yes	Have you used our after-hours call service? No	Have you used our after-hours call service?	Have you used our after-hours call service?
Would your recommend this practice to a family member or friend?	Would your recommend this practice to a family member or friend? Yes	Would your recommend this practice to a family member or friend? No	Would your recommend this practice to a family member or friend?	Would your recommend this practice to a family member or friend?
Would you like to see after-hours and/or Saturday clinic hours?	Would you like to see after-hours and/or Saturday clinic hours? Yes	Would you like to see after-hours and/or Saturday clinic hours? No	Would you like to see after-hours and/or Saturday clinic hours?	Would you like to see after-hours and/or Saturday clinic hours?

Other (please specify)

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* 8. How many years have your been a patient in our practice?

New patient

1 to 2 years

2 to 3 years

over 4 years

Question Title

* 9. Please rate your overall satisfaction with our practice.

	Excellent	Good	Fair	Poor
Please rate your overall satisfaction with our practice.	Please rate your overall satisfaction with our practice. Excellent	Please rate your overall satisfaction with our practice. Good	Please rate your overall satisfaction with our practice. Fair	Please rate your overall satisfaction with our practice. Poor

Other (please specify)

Question Title

* 10. Please give any suggestions you may have for us to better our practice and your satisfaction.