* 1. Was this your first experience with our office?

* 2. About how long did you wait in the front reception area?

* 3. From your experience with our clinic, please rate the following:

  Excellent Good Average Poor
Telephone Etiquette
Parking Facilities
Waiting Area
Billing Procedures
Scheduling
Cleanliness of the Office

* 4. The receptionist...

* 5. The Technician/Assistant...

* 6. Dr. Klein...

* 7. How would you rate the overall services of our office?

  Excellent Above Average Average Below Average Poor
Rating

* 8. Would you recommend us to a friend or relative?

* 9. Please add any comments or suggestions you might have to help us improve our business:

* 10. Please leave us your contact information if you would like to, it is NOT required...if left blank, your answers will be anonymous.

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