Southpointe Pediatrics Satisfaction Survey

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* 1. 1. Which provider did you see?

Dr. Asdell

Dr. Smith

Dr. Koepke

Dr. Workman

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* 2. What was the date of your appointment?

Date

Date

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* 3. How do you rate the quality of appointment services?

	Excellent	Very Good	Good	Fair	Poor
Friendliness, sensitivity, and courtesy received from the check-in staff	Friendliness, sensitivity, and courtesy received from the check-in staff Excellent	Friendliness, sensitivity, and courtesy received from the check-in staff Very Good	Friendliness, sensitivity, and courtesy received from the check-in staff Good	Friendliness, sensitivity, and courtesy received from the check-in staff Fair	Friendliness, sensitivity, and courtesy received from the check-in staff Poor
Friendliness, sensitivity, and courtesy received from the nursing staff	Friendliness, sensitivity, and courtesy received from the nursing staff Excellent	Friendliness, sensitivity, and courtesy received from the nursing staff Very Good	Friendliness, sensitivity, and courtesy received from the nursing staff Good	Friendliness, sensitivity, and courtesy received from the nursing staff Fair	Friendliness, sensitivity, and courtesy received from the nursing staff Poor
Friendliness, sensitivity, and courtesy received from the check-out staff	Friendliness, sensitivity, and courtesy received from the check-out staff Excellent	Friendliness, sensitivity, and courtesy received from the check-out staff Very Good	Friendliness, sensitivity, and courtesy received from the check-out staff Good	Friendliness, sensitivity, and courtesy received from the check-out staff Fair	Friendliness, sensitivity, and courtesy received from the check-out staff Poor
Friendliness, sensitivity, and courtesy received from your physician	Friendliness, sensitivity, and courtesy received from your physician Excellent	Friendliness, sensitivity, and courtesy received from your physician Very Good	Friendliness, sensitivity, and courtesy received from your physician Good	Friendliness, sensitivity, and courtesy received from your physician Fair	Friendliness, sensitivity, and courtesy received from your physician Poor

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* 4. Please rate the quality of telephone or in-office services as it pertains to:

	Excellent	Very Good	Good	Fair	Poor
Billing questions	Billing questions Excellent	Billing questions Very Good	Billing questions Good	Billing questions Fair	Billing questions Poor

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* 5.
If you rated any response at good or below, please explain why? Please share specific examples so that we may educate our staff and or review our policies. We are committed to making changes necessary to achieve an excellent rating.

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* 6. What improvements can we make to better serve you?