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* 3. Date of Visit:

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* 4. How would you rate the following?
First Impressions...

  Excellent Very Good Meets Expectations Fair Poor N/A
Convenience of appointment time
Scheduling of appointment
Location and directions
Greeting on arrival
Cleanliness
Wait time before you were seen
Quality of facilities

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* 5. While you were here...

  Excellent Very Good Meets Expectations Fair Poor N/A
Explanation about the exam/test/procedure
Privacy / confidentiality
Helpfulness / professionalism of staff
If you have a disability, did we meet your needs?
Were you made as comfortable as possible for your exam?
Were you treated with dignity and respect?
Quality of care received

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* 6. On a scale of 0-10, how likely are you to recommend us to a friend or relative, if they require the service?

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* 7. Would you return to us in future if you needed to?

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* 8. Overall, were you satisfied with your experience at our facility?

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* 9. Do you have any further comments or recommendations?

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* 10. Optional

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