Pediatric Clinic Visit Feedback Form
Parent/Guardian Name
Child's Name
Date of Visit
Email (optional)
How would you rate your overall experience?
Excellent
Good
Average
Poor
How satisfied were you with the following?
Friendliness of Staff
Very Satisfied
Satisfied
Neutral
Dissatisfied
Wait Time
Very Satisfied
Satisfied
Neutral
Dissatisfied
Cleanliness of Clinic
Very Satisfied
Satisfied
Neutral
Dissatisfied
Communication by Medical Staff
Very Satisfied
Satisfied
Neutral
Dissatisfied
Comments or Suggestions