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* 1. Please select your Kidzcare Pediatrics -Patient Centered Medical Home location for this survey -feedback

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* 2. date of your visit

Date

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* 3. New or Established Patient?

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* 4. Type of visit?

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* 5. At what email address would you like to be contacted?

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* 6. How friendly is your doctor's office Front Desk -Registration staff?

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* 7. Overall, how easy do you find it to schedule appointments?

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* 8. How quickly did our Front Desk staff return your phone calls?

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* 9. How easy was the check-in and registration process?

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* 10. Any other comment -feedback for front desk team?

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* 11. How was the cleanliness of the Front Office -Lobby waiting space?

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* 12. How comfortable is the Front Office waiting space?

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* 13. Was this visit a pleasant / friendly experience for your child?

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* 14. How convenient are the facility's office hours?

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* 15. Any other feedback for Front Office or Facility hours of operations?

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* 16. How courteous -friendly was the triage and nursing staff member who provided care to your child?

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* 17. How interested was the nursing and triage staff in your child's comfort?

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* 18. How helpful was triage and nursing staff in answering your questions / concerns?

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* 19. Overall, how often do you wait more than 15 minutes to see your nurse/medical assistant? (Wait time includes time spent in the waiting room/Lobby.)

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* 20. Any feedback for the triage and nursing staff?

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* 21. How courteous was the Doctor who provided treatment for your child?

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* 22. How was the quality of time spent by the Doctor with your child?

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* 23. How concerned was the Doctor with your child's care?

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* 24. Did your Doctor / Provider explain to you about your child's visit and answer your questions?

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* 25. Overall, how often do you wait more than 15 minutes to see your doctor? (wait time spent in the exam room)

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* 26. Any Feedback or comments on your Doctor /provider ?

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* 27. How was our concern of your child's privacy?

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* 28. How was our sensitivity towards you and your child's needs?

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* 29. How was our response to your complaints and concerns made during your visit?

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* 30. Any feedback or comments?

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* 31. How courteous was billing staff who processed your insurance/ bill?

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* 32. How was your privacy experience with billing staff while gathering your insurance/ billing information?

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* 33. How helpful and supportive was the billing staff while processing your insurance/ billing?

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* 34. Any feedback for insurance/ billing?

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* 35. Did you hear about our patient portal and its benefits (24 hour access to your medical records, medications, immunization, growth charts, lab results, prescription requests, visit summary etc),?

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* 36. Overall, how well did the staff work together to provide care and treatment to your child?

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* 37. How do you rate the overall care received during your visit?

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* 38. How likely are you to continue your visits in our clinic in the future?

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* 39. How likely are you to recommend our facility to others?

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* 40. Any feedback or suggestions to improve our facility and care provided to you and your child?

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