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* 1. I am (check one)

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* 2. My concerns were addressed

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* 3. My Questions were answered fully.

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* 4. The staff treated us well.

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* 5. I was satisfied with the service.

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* 6. Clinic we attended:

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* 7. Doctor we saw:

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* 8. Date of Service:

Date

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* 9. Please make any additional comments below.

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