Pediatric Clinic Patient Satisfaction Survey
Patient Information
Child's Name
Parent/Guardian Name
Date of Visit
Rate Your Experience
Ease of scheduling appointment
1
2
3
4
5
Friendliness of staff
1
2
3
4
5
Waiting time
1
2
3
4
5
Doctor's explanations and communication
1
2
3
4
5
Overall satisfaction
1
2
3
4
5
Feedback
What did you like most?
What can we improve?
Additional Comments