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Patient Satisfaction
1. Demographic Information
1
. Please complete the following fields of demographic information. This information will not be used to identify you, all surveys are submitted anonymously.
Age
Sex
Race/Ethnicity
Insurance Provider
Demographic Information
Under 18
18-25
25-35
35-50
50-70
70+
Please complete the following fields of demographic information. This information will not be used to identify you, all surveys are submitted anonymously. Demographic Information Age
Male
Female
Prefer not to say
Sex
Alaska Native / American Indian
White (Not Hispanic or Latino)
Black / African American
Pacific Islander
Hispanic or Latino (All Races)
Asian
Unknown
Race/Ethnicity
IHS Benificiary
Medicare
Medicaid
Denali Kid Care
Private Insurance
Uninsured
Insurance Provider
*
2
. Have you traveled to Nome from a village to recieve services within the past three months?
Have you traveled to Nome from a village to recieve services within the past three months?
Yes
No
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