1. Patient Survey

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* 1. What was the date of your visit?

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* 2. Was your appointment in the morning, afternoon, or evening?

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* 3. Are you a new patient to our clinic or a returning patient?

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* 4. My appointment was with:

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* 5. My appointment was at the:

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* 6. What factors influenced your initial choice of our office?

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* 7. The amount of time the doctor spent with me was adequate for my needs.

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* 8. The physician treated me with dignity, respect and patience.

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* 9. Did the doctor fully answer your questions?

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* 10. Did you feel the doctor was interested in you and your medical problem?

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* 11. How long did you wait to be seen by the doctor AFTER you checked in for your appointment?

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* 12. The physician gave me time to ask questions?

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