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* 3. How many times in the last 12 months have you received care at a walk-in clinic or emergency room?

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* 5. Have you been admitted to hospital in the last 12 months?

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* 6. If yes, did you have follow up from the clinic about your admission to hospital?

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* 8. If yes, have you reviewed the mdications you take in the last 12 months with your NP or the Pharmacist?

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* 9. When you see your health care provider, how often do they or someone else at the clinic give you an opportunity to ask questions about your recommended treatment?

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* 10. How often does your provider (this clinic) involve you in the decisions about your care/treatment?

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* 11. Does your provider or the person you see at the clinic spend enough time with you during your appointments?

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* 12. We are a team-based care model.  Please tell us whom you saw in the past 12 months at our clinic.  Please check all that apply.

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* 14. How would you rate your overall experience with the clinic?

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* 15. Would you recommend our services to friends or your family?  Check one only

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* 16. Please list any areas you feel we could improve or offer any suggestions you may have.

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