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* 1. Date of Visit

Please enter date:

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* 2. Please rate your satisfaction of our practice.

  Excellent Good Fair Poor
Ease of scheduling an appointment
Helpfulness and courtesy of the office staff
Time you waited in the reception area
Your Doctor's ability to listen and understand your needs
Overall satisfaction with our services

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* 3. Would you recommend us to a relative?

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* 4. Please give suggestions as to how we can improve:

T