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* 1. When did you last visit Wake Forest Pediatrics?

Date

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* 2. Was this the patient's first visit here?

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* 3. Front Office

  Very Poor Poor Fair Good Very Good N/A
Ease of scheduling your appointment.
Courtesy of person who scheduled your appointment.
Our helpfulness on the telephone
Availability of appointment

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* 4. Phone Nurse

  Very Poor Poor Fair Good Very Good N/A
Our helpfulness on the telephone.
Our promptness in returning your phone calls.

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* 5. During your visit.

  Very Poor Poor Fair Good Very Good N/A
Speed of the registration process.
Courtesy of the staff in the registration area.
Comfort and cleanliness of the waiting room.
Length of wait before going to an exam room.
Friendliness/courtesy of the nurse/assistant.

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* 7. Your care provider:

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Friendliness/courtesy of care provider.
Explanations the care provider gave you about your problem or condition
Instructions the care provider gave you about follow-up care.
Instructions the care provider gave you about referrals.
Likelihood of you recommending this care provider to others.
Explanations the care provider gave you about your medications.
Explanations the care provider gave you about your lab results.
Explanations the care provider gave you about your imaging results.
Felt listened to/respected.
Ability to get answers to your questions/concerns

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* 8. Overall assessment of visit.

  Very Poor Poor Fair Good Very Good N/A
Overall satisfaction of our practice.
Overall cleanliness of our practice.
Overall rating of care received during your visit.
Liklihood of you recommending our practice to others. 

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* 9. Other Comments

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* 10. Would you like someone from the office to contact you about your experience?

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* 11. If you answered yes to #10, please provide your name and phone number. 

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* 12. How can we improve the overall experience of our facility?

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