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* 1. Please select your provider

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* 2. How affordable do you find your sliding scale fees? 

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* 3. If fees are not affordable, would you like one of our case workers to contact you?

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* 4. Please enter your name and number if you would like to be contacted. 

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* 5. Insurance

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* 6. Age

Please select how well you think we are doing.

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* 7. EASE OF GETTING CARE
Scheduling, hours and location

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* 8. FRONT DESK
Friendly, helpful, answered questions

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* 9. Time spent in the waiting room

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* 10. Time spent in the exam room

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* 11. STAFF
Return calls, keep you up to date on test results, medications and referrals

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* 12. STAFF NURSES
Friendly,helpful and answers questions

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* 13. PROVIDER
Listens, takes time, answers questions, provides advice on self-care and treatment options

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* 14. PAYMENT
Collection of money/payment

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* 15. Facility: neat, clean comfort and safety

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* 16. Confidentiality:Personal information kept private

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* 17. Comments/Suggestions:

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