Children's Heart Center Patient Survey

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* 1. What date were you seen?

Date of Service

Date

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* 2. Who did you see?

Ruben Acherman MD

John Alexander DO

William Castillo MD

Michael Ciccolo MD

Beth Creel PhD

William Evans MD

Alvaro Galindo MD

Shilpi Garg MD

Katrinka Kip MD

Tina Kwan MD

Juan M Lehoux MD

Joseph Ludwick MD

Carlos Luna MD

Gary Mayman MD

Abraham Rothman MD

Robert Rollins MD

Ricardo Samson MD

Adam P Wheeler

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* 3. Which office did you go to?

3131 La Canada Street Suite 230 Las Vegas

653 N Town Center Drive Suite 114 Las Vegas

85 E Kirman Ave Suite 401 Reno

1470 Medical Parkway Suite 270 Carson City

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* 4. Please rate the following questions about the service you were provided

	Excellent	Good	Fair	Poor	N/A
How was our staff’s service when you first called our office to schedule an appointment?	How was our staff’s service when you first called our office to schedule an appointment? Excellent	How was our staff’s service when you first called our office to schedule an appointment? Good	How was our staff’s service when you first called our office to schedule an appointment? Fair	How was our staff’s service when you first called our office to schedule an appointment? Poor	How was our staff’s service when you first called our office to schedule an appointment? N/A
How was our staff’s service at check-in?	How was our staff’s service at check-in? Excellent	How was our staff’s service at check-in? Good	How was our staff’s service at check-in? Fair	How was our staff’s service at check-in? Poor	How was our staff’s service at check-in? N/A
How was our Medical Assistant’s service before seeing the doctor weighing, blood pressure, ECG, etc.)?	How was our Medical Assistant’s service before seeing the doctor weighing, blood pressure, ECG, etc.)? Excellent	How was our Medical Assistant’s service before seeing the doctor weighing, blood pressure, ECG, etc.)? Good	How was our Medical Assistant’s service before seeing the doctor weighing, blood pressure, ECG, etc.)? Fair	How was our Medical Assistant’s service before seeing the doctor weighing, blood pressure, ECG, etc.)? Poor	How was our Medical Assistant’s service before seeing the doctor weighing, blood pressure, ECG, etc.)? N/A
How were your wait times?	How were your wait times? Excellent	How were your wait times? Good	How were your wait times? Fair	How were your wait times? Poor	How were your wait times? N/A
How was our staff’s service at check-out?	How was our staff’s service at check-out? Excellent	How was our staff’s service at check-out? Good	How was our staff’s service at check-out? Fair	How was our staff’s service at check-out? Poor	How was our staff’s service at check-out? N/A
How was our staff’s service when you called with insurance or billing questions?	How was our staff’s service when you called with insurance or billing questions? Excellent	How was our staff’s service when you called with insurance or billing questions? Good	How was our staff’s service when you called with insurance or billing questions? Fair	How was our staff’s service when you called with insurance or billing questions? Poor	How was our staff’s service when you called with insurance or billing questions? N/A

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* 5. Is there anything we can do to improve your experience with Children’s Heart Center?

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* 6. Did any staff member’s service exceed or fail to meet your expectations?

Who?

What did they do?

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* 7. Would you like to be contacted regarding this survey?

Yes

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* 8. This patient survey can be anonymous. However if you would like our office to contact you please provide the following information.

Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

Children's Heart Center Nevada appreciates the time you took to respond to our survey. Should you have any questions please do not hestitate to contact our office. Thank you.