Patient Survey - The Children's Clinic

Appointment Information

My child was seen on*

My child's appointment was:*

Why did you visit The Children's Clinic*

My child saw*

Please rank from 1-5 (5 being the best)

The office staff was helpful and courteous.*

I was able to schedule an appointment in a timely manner.*

The waiting areas were welcoming, clean, and comfortable*

My child's appointement started and ended on time.*

My child's doctor or APN was/were helpful and courteous.*

If applicable, How would you rate the service and professionalism of the nursing staff?*

If applicable, How would you rate the service and professionalism of the lab work or x-ray technicians?*

I would recommend The Children's Clinic to my friends and family.*

How long did you have to wait to be seen by a doctor/nurse?*

What did you like most about your visit to our office?*

What did you like least about your visit to our office?*

What can we do to make future visits better for you and your child?*

We welcome your questions or comments.

If you would like for The Children's Clinic to respond to your comments, please provide your information below.

Name

First Last

Phone

Email

Address

Street Address City State ZIP Code

May we use your comments as a testimoninal on our website or other materials?

Your first name and town will be public. Your child's name will not be viewed by the public.