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* 1. Please give us feedback about your experience with your child's doctor today.

The doctor:

  Never Rarely Sometimes All the time No Opinion
Listened carefully to me
Explained things in a way I could understand
Treated me and my child with respect
Gave me advice on ways to help my child stay healthy

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* 2. I would recommend this doctor to my friends and family

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* 3. Name of Resident

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* 4. Date Survey Completed

Date

T