Prairie Mountain Health would like to hear your 
compliments, suggestions or concerns regarding your recent health care experience.
Your point of view is important to us. All responses will be kept confidential.

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* 1. My age in years:

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* 2. My gender:

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* 3. During my recent visit, I was a:

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* 4. Type of service received:

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* 5. Location where services were received:

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* 6. Please rate your visit by choosing the best answer for each of the following:

  Agree Disagree Not Applicable
I was happy with my overall experience.
The quality of services I received was satisfactory.
The facility was clean.
I had a positive experience with the staff.
I felt respected.
I was satisfied with the communication with the staff.
I felt safe.

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