* 1. Name: (Optional)

* 2. Date of admission:

Date:
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/

* 3. The staff treated me with courtesy and respect.

* 4. The staff took my problem seriously.

* 5. Enough time was devoted to my visit.

* 6. My privacy was respected.

* 7. My care was explained to me clearly and all questions were answered.

* 8. Call light was answered in a timely matter.

* 9. All of my needs were met.

* 10. Comments are our way of improving services for you.

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