* 1. In which age range(s) do(es) your child(ren) fall? (check all that apply)

* 2. How did you learn about Jackson Pediatrics? (check all that apply)

* 3. For which reason(s) did you chose Jackson Pediatrics as your child’s healthcare provider? (check all that apply)

* 4. What is (are) the best part(s) of your Jackson Pediatrics experience? (check all that apply)

* 5. Which part(s) of your Jackson Pediatrics experience could be improved? (check all that apply)

* 6. What could Jackson Pediatrics do to optimize your experience with our practice?

* 7. Jackson Pediatrics would be able to serve my family better if it hosted:

* 8. An exciting new component of our website (jacksonpediatrics.com) is the Patient Portal, where you can login for personal patient info such as immunization records, growth charts, prescribed medications and visit summaries. You can also use the Portal to contact us or request an appointment. In order to activate your family’s Portal account, you must have an email address on file. Please call us at 307.733.4627 to provide an email or let us know at your next visit. Alternatively, you may provide the necessary info here:

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