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* 1. Please enter the name of the provider during your last visit:

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* 2. Overall, how would you rate the care you received from your provider?

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* 3. How well did your provider listen to your needs?

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* 4. How well did your provider explain your treatment options?

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* 5. How well did your provider explain your follow-up care?

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* 6. How likely is it that you would recommend your provider to a friend or family member?

NOT AT ALL LIKELY
EXTREMELY LIKELY

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* 7. Overall, how satisfied or dissatisfied were you with your last visit to our office?

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* 8. Is there anything we could have done to improve your last visit?

T