Pediatrics West: Home

3555 Lutheran Parkway Suite 200

Wheat Ridge, CO80033

(720) 284-3700 More Offices

PEDIATRICS WEST PATIENT SURVEY

It is our goal to give your child the best possible medical care. To do so, it is important that we know your thoughts about the care you are receiving. We need to know what we are doing right and in what areas we can improve. Your comments will be strictly confidential. Space is provided at the end of this survey for any additional comments you may wish to make. Thank you for your help.

Physicians Name :

Is this your:
first visit, or return visit?
Why did you choose this office for your medical treatment? Please check one.:
Near my office or home Referred by another patient Telephone listing Referred by the medical society Referred by another physician Picked from my insurance listing Referred by the Emergency Room Other
If Other, please fill in the blank :

How long did it take to get in for your appointment?:
Same Day Within 24 hours Within one week 2 weeks 3-4 weeks Over 4 weeks
Please describe your initial telephone call: (check one):
The telephone was answered promptly I was put on hold The line was busy I did not make the initial call
Please rate the person who answered your call::
1 (Lowest) 2 3 4 5 (Highest)
How were you treated when you arrived at the reception desk?:
1 (Lowest) 2 3 4 5 (Highest)
How long did you have to wait to see your physician? :
(in minutes)
Please rate the nurse/assistant:
1 (Lowest) 2 3 4 5 (Highest)
How was the attitude of the office staff?:
1 (Lowest) 2 3 4 5 (Highest)
Were you satisfied with the the amount of time the doctor spent with you?:
1 (Lowest) 2 3 4 5 (Highest)
Please rate the physician�s interest in your problem.:
1 (Lowest) 2 3 4 5 (Highest)
How would you assess your doctor�s explanation of your child�s illness and treatment?:
1 (Lowest) 2 3 4 5 (Highest)
Were you satisfied with the medical treatment your child received?:
1 (Lowest) 2 3 4 5 (Highest)
Did we provide you with helpful patient educational information?:
Yes No n/a
If the physician was running behind, did the staff explain this to you? :
Yes No n/a
Which category best describes the reason for today�s visit to our office?:
Emergent Urgent Follow Up Non-Urgent Visit Physical Exam/Well Care New Patient Visit
Please select the age of the patient:
0-1 2-6 7-12 13-18 19 and older
Would you like someone to contact you personally about any of your questions or concerns? :
Yes No (If No, please include your name and phone number)
Name (Optional) :

Telephone Number (Optional) :

Please free to write any comments you may have regarding your visit today.:

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