Pediatric ENT: Ear, Nose and Throat Medical Procedures

Survey

Thank you for taking the time to comment on today's visit. We want you to be
satisfied with your experience. Nothing is more important to us than making
sure you received excellent patient care. Our physicians and office staff are
here to make you and your child feel better.

Today's Date:

Physician/provider you saw today:

How long has your child been a patient at this practice:

This is my first visit	1-2 Years
Less than 6 months	2-5 Years
6 months-1 year	5 years or more

How satisfied are you with the following:		Excellent	Acceptable	Poor
1.	Visit overall
2.	Availability of appointment
3.	Scheduling of appointment
4.	Appearance of office
5.	Wait time in office
6.	Time with physician
7.	Front office staff friendly and courteous
8.	Nurses and Medical Assistants professional and courteous
9.	Physician/ARNP answered all of your questions

1. What did we do that enhanced your visit? (Please include names of any employees so that they can be thanked personally)

2. What can we do to make your next visit better?

3. please write any additional comments or questions

Name (optional)
Phone#

Would you like someone to call you about your visit? yes no