Please take a minute to answer 10 simple questions:

Prior to taking our survey, please visit the link below if you need to research whether or not your doctor(s) are affiliation with Atlantic Health System.
www.atlantichealth.org/locations.html

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* 1. First Name

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* 2. Last Name

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* 3. In the past six months, have you or a dependent seen a doctor affiliated with the Atlantic Health System?

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* 4. If you answered yes in question three above, how many times?

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* 5. In the past six months, have you or a dependent undergone a treatment or procedure at an Atlantic Health System hospital or facility?

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* 6. If you answered yes to question four above, about how many times?

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* 7. During the next six months, do you, or a dependent, plan to schedule an appointment with a doctor affiliated with the Atlantic Health System?

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* 8. During the next six months, do you, or a dependent, intend to have a medical procedure at an Atlantic Health System hospital or medical facility?

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* 9. What is the name of your doctor(s) that participates with Atlantic Health System?

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* 10. What is the name of the hospital that you utilize affiliated with the Atlantic Health System?

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