It is our goal to give you the best possible medical care. To do that, it is important that we know your thoughts about the care you are receiving. Thank you for completing this survey!

* 1. What was the date of your visit?

Date / Time

* 2. Which office did you visit?

* 3. Which provider did you see?

* 4. Were you able to see the provider you requested?

* 5. What is your child's ethnicity?

* 6. What is your child's race? (Please check all that apply.)

* 7. What is your current insurance company?

* 8. What is your child's primary language?

* 9. Were you offered an appointment date and time that was convenient for you?

* 10. When you arrived at the office for your appointment, did the front office staff greet you promptly and in a friendly manner?

* 11. After you checked in at the front desk, how long did you have to wait until you were taken to a room?

* 12. How would you rate our nursing staff?

* 13. How would you rate our laboratory staff?

* 14. Did the nurse and provider treat you with respect, listen to you, and allow you to ask questions?

* 15. Did you understand what the provider told you about your child's condition and treatment?

* 16. Did the provider explain things in a way that was easy for your child to understand?

* 17. Did the provider or nurse talk with you about specific goals for your child's health?

* 18. Did the provider or nurse ask you if there are things that make it hard for you to take care of your child's health?

* 19. If you answered yes to the previous question, did the provider or nurse offer information on community resources or a phone call with our care management team?

* 20. Was the provider aware of any care your child received from specialists or in a hospital or ER?

* 21. Did the provider or nurse talk to you about all the prescription medications your child is taking?

* 22. How would you rate your overall experience at our office?

* 23. Is there anything else you want us to know?

Thank you for taking the time to complete this survey!