Blue Argo, Inc.
Nataloni Pediatrics Patient Satisfaction Survey
Help us build a better practice! Tell us what you think about your experience with us!
Your responses will be held in confidence, unless you give us permission to share your feedback with others.
Your Name:
First
Last
Your Email Address:
Your Contact Information:
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
United States
United Kingdom
Australia
Canada
France
New Zealand
India
Brazil
----
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Democratic Republic of the Congo
Republic of the Congo
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Country
How many of your children are treated at Nataloni Pediatrics?
1
2
3
4
5 or more
How long have you been a patient of Dr. Nataloni?
Less than six months
Less than one year
Between 1-2 years
Between 2-5 years
Between 5-7 years
Between 7-10 years
More than 10 years
How did you hear about our practice?
Friend
Family Member
Another Doctor
Web or Personal Research
Advertisement
Other
If you came through a patient referral, we'd like to thank this individual. Please provide us with his or her name!
Please rank your experience at our office in the following areas
Using a scale of 1-5, where one is excellent and 5 is poor.
Office Layout and Setup
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Office Aesthetic and Amenities
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Friendliness of Staff
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Responsiveness of Office Staff
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Ease of Scheduling a Visit
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Wait Time Prior to Visit
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Billing and Insurance Procedures
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Quality of Our Web Site
1 - excellent
2- Fair
3 - Neutral/No Opinion/Okay
4- Needs improvement
5- Poor
Now tell us a little bit about your visit!
Who examined your child?
Dr. Nataloni
What type of visit was your last visit with us?
New Patient
Well Visit
Sick Visit
Physical Examination
Was your examination comfortable for you and your child?
Very comfortable
Somewhat Comfortable
A Little Uncomfortable
Very Uncomfortable
Were procedures and options clearly explained to you and (if applicable) your child?
Yes
Somewhat
Not At All
Do you feel your physician listened actively to your concerns?
Yes
Somewhat
Not at All
Do you feel you had enough time with your physician?
Yes
Somewhat
Not at All
In general, do you feel that your treating physician exhibited care, concern, and compassion for you and your child?
Yes
Somewhat
Not at All
Would you recommend Nataloni Pediatrics to your friends and/or family?
Yes
No
Please enter any feedback or recommendations you may have that will help us improve your experience in the future:
May we contact you regarding your feedback? (If so, please make sure your contact information above is provided)
Yes
No
May we use your feedback/testimonial on our web site?
Yes
No
Do Not Fill This Out