Please rate the following:

A. YOUR APPOINTMENT:

* Ease of making an appointment

* The efficiency of the check-in process

* Waiting time in the reception area

* Waiting time in the exam area

B. OUR STAFF:

* The friendliness and courtesy of the receptionist

* The caring concern of our nurses/medical assistants

C. YOUR VISIT WITH THE PROVIDER:
(Doctor, Physician Assistant, Aestetician)

* Willingness to listen carefully to you

* Taking time to answer your questions

* Amount of time spent with you

D. YOUR OVERALL SATISFACTION WITH:

* Our practice

* The quality of your medical care

* How did you hear about our office?

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

SOME INFORMATION ABOUT YOU:

* Are you:

* Who did you see for your appointment?

* Patient name?

* Are you male or female?

* What is your age?

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