1. Patient Care Improvement Survey

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* 1. Ease of making your appointment

  Poor Fair Good Very Good Excellent
Check one

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* 2. Appointment available within a reasonable amount of time

  Poor Fair Good Very Good Excellent
Check one

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* 3. Efficiency of check-in process

  Poor Fair Good Very Good Excellent
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* 4. Professionalism of our receptionist

  Poor Fair Good Very good Excellent
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* 5. Waiting time prior to seeing a physician/nurse practitioner

  Poor Fair Good Very good Excellent
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* 6. Keeping you informed if your appointment time was delayed

  Poor Fair Good Very Good Excellent N/A
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* 7. Professionalism of the Medical Assistant/Nurse

  Poor Fair Good Very Good Excellent N/A
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* 8. The physician/nurse practitioner listening to you and taking time to answer questions

  Poor Fair Good Very Good Excellent
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* 9. Who was your appointment with?

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* 10. Responsiveness to requests for medication refills

  Poor Fair Good Very Good Excellent N/A
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* 11. Your test results reported in a reasonable amount of time

  Poor Fair Good Very Good Excellent N/A
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* 12. Your overall satisfaction with the quality of medical care you received

  Poor Fair Good Very Good Excellent
Check one

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* 13. IF THERE IS ANY WAY WE CAN IMPROVE OUR SERVICES TO YOU, PLEASE TELL US ABOUT IT:

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* 14. Would you recommend the physician and/or nurse pratitioner to others?

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* 15. Have you been to our office before?

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* 16. If yes to question 15-was the experience

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* 17. Date of your appointment

MM/DD/YYYY

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* 18. Name (optional):

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* 19. Your age

T