We would like to know how you feel about the services we provide so we can make sure we are meeting your needs.  Your responses are directly responsible for improving these services.  All responses will be kept confidential and anonymous.

Which office do you usually visit?

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* 1. Which office do you usually visit?

Which provider do you usually see if you need a check-up or want advice about a health problem?

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* 2. Which provider do you usually see if you need a check-up or want advice about a health problem?

Gender of your child(ren)?

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* 3. Gender of your child(ren)?

Age of your child(ren):

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* 4. Age of your child(ren):

How did you learn about Haywood Pediatrics?

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* 5. How did you learn about Haywood Pediatrics?

Type of Insurance?

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* 6. Type of Insurance?

Please enter a response for each question below:

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* 7. Please enter a response for each question below:

  Always Usually Sometimes Never N/A
In this practice, when I phone to get an appointment for care my child needs right away, I am able to get an appointment as soon as I feel my child needs one.
In this practice, when I phone to get an appointment for a check-up or routine care, I am able to get an appointment as soon as I feel my child needs one. 
When I phone the office during regular office hours, I get an answer to my medical question that same day.
When I phone the office after regular office hours, I get an answer to my medical question as soon as I need it.
My child’s doctor gives me easy to understand instructions about how to take care of my child’s health problems or concerns. 
The doctor’s assistants, receptionists and other staff treat my child and family with respect and care.
When my child’s doctor orders blood tests, x-rays, other tests, someone from the office follows up to give me the results.
My child’s doctor communicates with other health professionals about my child’s care (such as specialists, therapists).
In the last 12 months, how often did someone in the practice talk with you about specific goals for your child’s health?
Some other questions we have for you: 

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* 8. Some other questions we have for you: 

  Excellent Very Good Good Fair Poor
How would you rate the comfort and/or cleanliness of our office?
In general, how acceptable is the wait time before you saw the provider?  
In general, how acceptable is the time your provider spends with you?
Please tell us about anything we do well AND how we can improve the care and services we offer:

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* 9. Please tell us about anything we do well AND how we can improve the care and services we offer:

Thank you for your feedback and time!
*If you would like to discuss anything about our office or regarding this survey with one of our Office Managers, please leave your name and phone number ONLY if you want us to contact you:

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* 10. Thank you for your feedback and time!
*If you would like to discuss anything about our office or regarding this survey with one of our Office Managers, please leave your name and phone number ONLY if you want us to contact you:

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