1. Patient Survey

What was the date of your visit?

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* 1. What was the date of your visit?

Was your appointment in the morning, afternoon, or evening?

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* 2. Was your appointment in the morning, afternoon, or evening?

Are you a new patient to our clinic or a returning patient?

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* 3. Are you a new patient to our clinic or a returning patient?

My appointment was with:

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* 4. My appointment was with:

My appointment was at the:

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* 5. My appointment was at the:

What factors influenced your initial choice of our office?

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* 6. What factors influenced your initial choice of our office?

The amount of time the doctor spent with me was adequate for my needs.

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* 7. The amount of time the doctor spent with me was adequate for my needs.

The physician treated me with dignity, respect and patience.

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* 8. The physician treated me with dignity, respect and patience.

Did the doctor fully answer your questions?

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* 9. Did the doctor fully answer your questions?

Did you feel the doctor was interested in you and your medical problem?

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* 10. Did you feel the doctor was interested in you and your medical problem?

How long did you wait to be seen by the doctor AFTER you checked in for your appointment?

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* 11. How long did you wait to be seen by the doctor AFTER you checked in for your appointment?

The physician gave me time to ask questions?

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* 12. The physician gave me time to ask questions?

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