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* 1. Which office was your last appointment?

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* 2. When was your last appointment?

Date

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* 3. Ease of setting your appointment. Greeting by our receptionist when you arrived.
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 4. Cleanliness/Neatness of the waiting room
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 5. Cleanliness/Neatness of the patient procedure room. 
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 6. Length of time you had to wait before you were called for your appointment
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 7. Friendliness of our office staff
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 8. Friendliness of the provider, the ability of the provider to put you at ease 
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 9. Quality of service performed
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 10. The degree to which your concerns were addressed by either the nurse or provider
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 11. The ease of checking out and paying after the appointment?
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 12. How likely is it that you would recommend our office to your family members, co-workers, and friends?
 In your own words, let us know any positive experiences you had or issues or concerns you may have about our services or offices practices and procedures.
1 - Poor, 2 - Fair, 3 - Good, 4 - Very Good, 5 - Excellent

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* 13. Would you like to provide us with your contact information? 

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