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Please fill out for the person receiving services (i.e. self, child, parent)

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* 1. I received...

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* 2. Appointment started promptly

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* 3. Center facilities were acceptable

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* 4. Professionalism of the receptionist was appropriate

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* 5. Professionalism of the clinician was appropriate

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* 6. Fees for service were affordable

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* 7. I experienced quality service while being tested

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* 8. Results were explained in a way I could understand

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* 9. I would recommend the Center to others

Please answer the following questions if you were fit with a hearing aid or cochlear implant:

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* 10. My device was ready when promised

Overall Experience:

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* 11. Why did you choose the Center?

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* 12. The best part about the services I received was...

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* 13. How can we change our services to benefit you more?

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* 14. Age Range

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* 15. Gender:

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