Excellent	Very good	Good	Fair	Poor
1. The ease of scheduling today’s visit was
2.The convenience of the office hours was
3. The receptionist’s helpfulness was
4.While here, the level of staff courtesy & respect was
5. The payment/billing process for today’s visit was
6. The comfort & cleanliness of the reception area was
7. The convenience of office location & parking was
Medical Care
	Excellent	Very Good	Good	Fair	Poor
1. The comfort & cleanliness of the exam room was
2. The skill of the medical assistant was
3. The on-time arrival of the doctor/pa/np to see me was
4. The courtesy/friendliness of the doctor was
5. The amount of exam time & attention from the doctor was
6. The explanation by the doctor of my child’s condition was
7. The instructions the doctor gave me to follow were
8. The quality of the care I received from the doctor today was
9. Overall, I rate today’s visit to this office as
General Comments
1. Please list the name of anyone who was especially helpful during your visit to our office:
2. If you had to change your insurance to be able to continue coming to this office, would you?
Yes No (please check one)
3. Overall, if there is one thing you could change about this office/staff/doctor, it would be:

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