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* 1. What is your name? (Optional)

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* 2. When did you visit our practice?

Date

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* 3. Which practitioner did you see during your visit?

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* 4. Is this the practitioner you asked for while making your appointment? 

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* 5. Which office did you visit during your appointment? 

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* 6. How easy was it for you to schedule an appointment at our practice?

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* 7. How would you rate the overall care you received at our practice?

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* 8. How would you rate the Medical Assistant/Nurse?

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* 9. How would you rate our office staff?

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* 10. Is there any staff member you would like to comment about? (Example: Practitioner, MA, Operator)

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* 11. How satisfied were you with your wait time?

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* 12. How easy was it for you to obtain follow-up information? (Example: Blood Work/Test Results)

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* 13. How many years have you been visiting our practice?

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* 14. How likely would you be to recommend Dr. Scafuri & Associates to Friends and Family?

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i We adjusted the number you entered based on the slider’s scale.

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* 15. Please leave a review/additional comments about your experience at Dr. Scafuri & Associates. 

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* 16. Would you be willing to allow us to feature your review on our site? If we use your review, we won't use your name, just your initials.

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