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* 1. Date:

Date:

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* 3. Was the clinic clean?

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* 4. Were the clinic employees friendly?

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* 5. Were you satisfied with the care received today?

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* 6. Are you usually able to get an appointment when you need one?

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* 7. Do you usually get test results in a reasonable amount of time?

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* 8. Do you feel that your culture and traditions were respected?

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* 9. Comments:

T