PATIENT SURVEY

Beach Pediatrics
A Division of Allied Pediatrics of New York
312 Long Beach Road
Island Park, N.Y. 11558
P: (516) 897-5000 F: (516) 431-7519

Quality Service Survey

Please print and either mail the form to our office or fax it to 516 431 7519.

Child’s Name (optional) ___________________________________ Date of Visit: __________

1. Please tell us the name of the physician you saw today?
____ Dr Jaffe
____ Dr Jonisch
____ Dr Aiuto
____ Dr Bilello
2. I do not have to wait more than I should once I’m in the office.
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree
o Not Applicable

3. Nursing staff is skillful, helpful and respectful.
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree
o Not Applicable

4. The doctor I saw today is skillful and helpful.
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree
o Not Applicable

5. The doctor I saw today communicates well and cares about me.
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree
o Not Applicable

6. I am confident that I can take care of and control most of my child’s health problems.
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree
o Not Applicable


7. The office was clean.
o Disagree
o Agree



8.I would recommend this doctor’s office to family or friends.
o Strongly Disagree
o Disagree
o Agree
o Strongly Agree
o Not Applicable

Please feel free to communicate your thoughts with us here or in person. Please print and either mail the form to our office or fax it to 516 431 7519. Thank you
Comments: ___________________________________________________________
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Thank you very much for your time. We always strive to improve in order to make your experience a better one.