Please rate the following:

A. YOUR APPOINTMENT:
Ease of making an appointment

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* Ease of making an appointment

The efficiency of the check-in process

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* The efficiency of the check-in process

Waiting time in the reception area

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* Waiting time in the reception area

Waiting time in the exam area

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* Waiting time in the exam area

B. OUR STAFF:

The friendliness and courtesy of the receptionist

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* The friendliness and courtesy of the receptionist

The caring concern of our nurses/medical assistants

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* The caring concern of our nurses/medical assistants

C. YOUR VISIT WITH THE PROVIDER:
(Doctor, Physician Assistant, Aestetician)
Willingness to listen carefully to you

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* Willingness to listen carefully to you

Taking time to answer your questions

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* Taking time to answer your questions

Amount of time spent with you

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* Amount of time spent with you

D. YOUR OVERALL SATISFACTION WITH:
Our practice

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* Our practice

The quality of your medical care

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* The quality of your medical care

How did you hear about our office?

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* How did you hear about our office?

If there is any way we can improve our services to you, please tell us about it:

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* If there is any way we can improve our services to you, please tell us about it:

SOME INFORMATION ABOUT YOU:
Are you:

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* Are you:

Who did you see for your appointment?

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* Who did you see for your appointment?

Patient name?

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* Patient name?

Are you male or female?

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* Are you male or female?

What is your age?

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* What is your age?

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