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Post-Visit Patient Satisfaction Template
Little Oaks Pediatrics
Survey post patient visit
OK
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
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
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
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
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
6.
Overall, how would you rate the service you received from the staff at our office?
Excellent
Very good
Good
Fair
Poor
7.
Is there anything we could have done to improve your last visit?
