Feedback

1

Date of the visit:* This field is required.

Date

2

Were appointment times available within a reasonable time?* This field is required.

Yes

No

3

Comments?

4

Were you able to get an appointment within the time frame that you wanted it?* This field is required.

Yes

No

5

Comments?

6

How likely are you to schedule a TeleVisit (online virtual visit) instead coming into the office to see the doctor?* This field is required.

LIKELY

UNLIKELY

UNSURE

7

What time of day would you prefer to have a telehealth visit? (mornings, early afternoons, late afternoon)* This field is required.

Morning

Early afternoon

Late afternoon

8

Was the front desk staff friendly and courteous to you?* This field is required.

Yes

No

9

Comments?

10

Were the office nurses friendly and courteous to you?* This field is required.

Yes

No

11

Comments?

12

Did the doctor spend enough time with you to address your needs and answer all your questions?* This field is required.

Yes

No

13

Comments?

14

Did the doctor listen and address any questions or doubts you have regarding your child’s care and provide the appropriate answers?* This field is required.

Yes

No

15

Comments?

16

Has your child had any labs or x-rays ordered by our doctor?* This field is required.

Yes

No

17

If the answer to above question is yes, were you notified of the results in a timely manner? * This field is required.

Yes

No

18

Has our office completed any specialist referrals for your child?* This field is required.

Yes

No

19

If the answer to above question is yes, do you feel that our office handled this in a timely manner? * This field is required.

Yes

No

20

Upon leaving, did you understood the diagnosis and medical treatments recommended by the doctor?* This field is required.

Yes

No

21

Comments?

22

Have we provided you with educational materials to help you understand the reason for your child’s visits?* This field is required.

Yes

No

23

If the answer to above question is yes, was the information helpful and/or did it answer all of your questions?* This field is required.

Yes

No

24

Do you feel that our care team addressed all of your child’s health care needs?* This field is required.

Yes

No

25

Comments?