Post-Visit Patient Satisfaction Template

Little Oaks Pediatrics

Survey post patient visit

Question Title

* 1. How easy or difficult was it to schedule your well child appointment at a time that was convenient for you?

Very easy

Somewhat easy

Neither easy nor difficult

Somewhat difficult

Very difficult

Question Title

* 2. How easy or difficult was it to schedule your appointment for an urgent visit ?

Very easy

Somewhat easy

Neither easy nor difficult

Somewhat difficult

Very difficult

Question Title

* 3. How easy or difficult was it to schedule your sick visit appointment on a Saturday or after 5pm ?

Very easy

Somewhat easy

Neither easy nor difficult

Somewhat difficult

Very difficult

Question Title

* 4. How well did your provider listen to your needs and did you feel your opinion was respected?

Extremely well

Very well

Somewhat well

Not so well

Not at all well

Question Title

* 5. How well did your provider communicate with you regarding lab or imaging results and referrals?

Extremely well

Very well

Somewhat well

Not so well

Not at all well

Question Title

* 6. Overall, how would you rate the service you received from the staff at our office?

Excellent

Very good

Good

Fair

Poor

Question Title

* 1. How easy or difficult was it to schedule your well child appointment at a time that was convenient for you?

Question Title

* 2. How easy or difficult was it to schedule your appointment for an urgent visit ?

Question Title

* 3. How easy or difficult was it to schedule your sick visit appointment on a Saturday or after 5pm ?

Question Title

* 4. How well did your provider listen to your needs and did you feel your opinion was respected?

Question Title

* 5. How well did your provider communicate with you regarding lab or imaging results and referrals?

Question Title

* 6. Overall, how would you rate the service you received from the staff at our office?

Question Title

* 7. Is there anything we could have done to improve your last visit?