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1. What department were you seen in today? (Required.)

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2. Pleas select the appropriate age range for yourself (the patient). (Required.)

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3. Appointment available within a reasonable time?

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4. Overall efficiency of check-in process?

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5. Wait time in the exam room?

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6. If appointment was delayed, how well did we do at keeping you informed of the delay?

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7. If a referral was required, how did we do at making the process easy for you?

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8. Caring / Concern / Professionalism of the NTHS staff?

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9. Phone calls are returned promptly?

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10. Explanation of your health concerns / questions?

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11. Test results available within a reasonable amount of time?

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12. Clarity and effectiveness of the health information material provided?

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13. Wait time for your in-clinic prescriptions to be filled?

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14. Cleanliness of the clinic?

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15. Overall satisfaction of care from your medical home provider?

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16. Suggestions for improvement or Compliments:

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