Pediatric Clinic Visit Feedback Form
Date of Visit
Child's Name
Child's Age
Provider Seen
Reason for Visit
Waiting Time
Less than 15 minutes
15 - 30 minutes
More than 30 minutes
Staff Friendliness
Excellent
Good
Fair
Poor
Facility Cleanliness
Excellent
Good
Fair
Poor
Provider's Care and Communication
Excellent
Good
Fair
Poor
Overall Experience
Excellent
Good
Fair
Poor
Suggestions/Comments