PATIENT SATISFACTION

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* 1. What is your age? Cuántos años tienes?

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* 2. What is your gender?

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* 3. Which race/ethnicity best describes you? (Please choose only one.)

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* 4. What location are you visiting today?

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* 5. Ease of Getting Care:

  GREAT GOOD OK FAIR POOR
Ability to Be Seen
Hours Center is Open
Prompt Return on Calls

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* 6. Waiting:

  GREAT GOOD OK FAIR POOR
Time in Waiting Room
Time in Exam Room
Waiting for Test to Be Performed
Waiting for Test Results

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* 7. PROVIDER: DOCTOR, NURSE PRACTITIONER, DENTIST, PHYSICIAN ASSISTANT

  GREAT GOOD OK FAIR POOR
LISTENS TO YOU
TAKES ENOUGH TIME WITH YOU
GIVES YOU GOOD ADVICE AND TREATMENT
EXPLAINS WHAT YOU NEED TO KNOW

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* 8. INTAKE NURSE, MEDICAL ASSISTANT, DENTAL ASSISTANT

  GREAT GOOD OK FAIR POOR
FRIENDLY AND HELPFUL TO YOU
ANSWERS YOUR QUESTIONS

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* 9. STAFF: ALL OTHERS

  GREAT GOOD OK FAIR POOR
FRIENDLY AND HELPFUL TO YOU
ANSWER YOUR QUESTIONS

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* 10. PAYMENT

  GREAT GOOD OK FAIR POOR
WHAT YOU PAY FOIR VISIT
EXPLANATION OF CHARGES
COLLECTION OF PAYMENT/MONEY

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* 11. FACILITY

  GREAT GOOD OK FAIR POOR
NEAT AND CLEAN BUILDING
EASE OF FINDING WHERE TO GO
COMFORT AND SAFETY WHILE WAITING
PRIVACY

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* 12. CONFIDENTIALITY

  GREAT GOOD OK FAIR POOR
KEEPING MY PERSONAL INFORMATION PRIVATE
LIKELIHOOD OF REFERRING FRIENDS AND RELATIVES TO US

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* 13. DO YOU CONSIDER THIS CENTER YOUR REGULAR SOURCE OF  HEALTH CARE

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