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Customer Survey and Comments

Hometown Family Care and Kids Care Pediatrics highly values the opinions of our customers and patients. Please complete the customer survey below and provide us with any comments that you would like for us to review so that we can continuously improve our services to best fit your needs. 

 

Patient Name:
Patient E-mail:
Patient Phone #:
Patient Age:


Visit Information
Which provider did you see:
Dr. Christopher Bailey
Crystal Blair, APRN
Kendra Bailey Burgess, PA-C
Dr. Jason RH Castle
Kelley Cochran, PA-C
Dr. Dustin Devers
Dr. Leslie Devers
Kari Jones, PA-C
Dr. Jeffery Potter
Dr. Kate Shutts
Allyson Stephens, PA-C
Jennifer Teeters, APRN
Carla McCarty Thacker, PA-C
Ginny Fuller Watkins, PA-C
  *
Did you have an appointment:
Yes
No (walk in)


Visit Ratings
How long did you wait in the waiting area:
Less than 15 minutes
15 to 30 minutes
30 minutes to 1 hour
More than 1 hour

How long did you wait in the exam room:
Less than 5 minutes
5 to 15 minutes
15 minutes to 30 minutes
30 minutes to 1 hour
More than 1 hour

Overall, how satisfied were you with your visit:
Extremely Satisfied
Satisfied
Neither Satisfied nor Dissatisfied
Dissatisfied
Extremely Dissatisfied

Would you recommend this healthcare provider to a friend:
Yes
No
Unsure

Do you plan to visit this healthcare provider again:
Yes
No
Unsure


Comments and Suggestions
Please share your comments and suggestions:
* Required field