Today's visit:

Here are some questions about your most recent visit to our office.
Kindly complete this questionnaire. Thank you so much!

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* 1. Were you able to make an appointment at a convenient time?

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* 2. On the day of your appointment did you have to wait more than 20 minutes to see your provider?

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* 3. Was our staff courteous and professional?

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* 4. Did you have a favorable provider visit?

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* 5. Were all your concerns and questions addressed during your visit?

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* 6. How would you rate your satisfaction with getting the help that you came here for?

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* 7. What is your age?

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* 8. Are you male or female?

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* 9. What can we do to improve your next visit? Please provide name so we can follow-up.

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* 10. Would you recommend us to a family member or friend?

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