Arizona Pediatric Cardiology Consultants
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APCC Patient Survey

* Indicates required information

Please provide the following information to help us best serve you.

First Name
Last Name
Email
Phone
1. *
Date of Visit
2. *
Office Location

If Other, please specify:
3. *
Physician Seen

If Other, please specify:
4. *
Nurse Practitioner or Nurse Specialist Seen
5. *
Rate the ease of making an appointment.
6. *
Rate the length of time on hold when scheduling the appointment.
7. *
Was an appointment available within a timeframe you consider reasonable?
8. *
Type of appointment?
9. *
When was your appointment scheduled for?

If Other, please specify:
10. *
Rate the courtesy of the person who made your appointment.
11. *
Rate the courtesy of the front desk staff.
12. *
Rate the check-in process.
13. *
Rate the amount of time you spent in the waiting room after check-in.
14. *
How much time did you spend in the waiting room after check-in?
15. *
Did the provider (physician or nurse practitioner) introduce himself or herself?
16. *
Did the medical assistant introduce himself or herself?
17. *
Rate the courtesy of the provider (physician or nurse practitioner) during your visit.
18. *
Rate the courtesy of the medical assistant during your visit.
19. *
Rate the medical assistant's ability to ease your fears if you were anxious about the visit.
20. *
Did the medical assistant explain what tests were being performed?
21. *
What tests did you have performed?

If Other, please specify:
22. *
Rate the courtesy of the person who performed the echocardiogram (heart ultrasound).
23. *
Did the person explain the echocardiogram test before performing it?
24. *
Did the provider (physician or nurse practitioner) explain all test results in a manner that you could understand?
25. *
Did the provider (physician or nurse practitioner) listen carefully to you and answer your questions?
26. *
Rate the staff's effort to provide compassionate care.
27. *
Rate your visit overall.
28. *
Would you recommend this office to your family or friends?
29.
Is there anything we can do to make future office visits better?
30.
Do you have a question or concern that you would like somebody to contact you about? If so, please provide your phone number or email and a brief explanation of your question or concern.
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