Please answer the questions on a scale of 1-5
(1=dissatisfied, 3=satisfied, 5=extremely satisfied)

1. How satisfied are you that your phone calls are returned in a timely fashion?
   1 2 3 4 5

2. How satisfied are you with the amount of time on hold when you call?
   1 2 3 4 5

3. How satisfied are you with the days and times Metropolitan Pediatrics is open to schedule appointments for your children?
   1 2 3 4 5

4. How satisfied were you with the way you were treated by the receptionist at your most recent visit?
   1 2 3 4 5

5. How satisfied were you with the amount of time (if any) in the waiting room?
   1 2 3 4 5

6. How satisfied were you with the way you were treated by the nursing staff at your most recent visit?
   1 2 3 4 5

7. How satisfied were you that the doctor explained things in a way you could understand?
   1 2 3 4 5

8. How satisfied were you with the length of time the doctor spent with your child?
   1 2 3 4 5

9. How satisfied were you overall with your experience during the visit?
   1 2 3 4 5

10. Would you recommend Metropolitan Pediatrics to others?
    1 2 3 4 5

Name of Physician seen on this visit
Select physician Anderson Barsotti Bell Bix Bradeen Burton Ching Chiu Deenadayalu Dunn Egsieker Ferre Gyerko Hamel Hartman Heichelheim Lickteig Meyer Moore Moshofsky Neace Rydell Willey

Please send us your comments or suggestions

OPTIONAL INFORMATION

Date of visit:   Month -- 01 02 03 04 05 06 07 08 09 10 11 12 Day -- 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year -- 2010 2009

Child's name:

May we contact you regarding your satisfaction with your visit? yesno
If so, what is the best phone number to reach you?