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* 1. Please identify the location(s) where you have received services from the Thames Valley Family Health Team.

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* 2. Which healthcare provider did you connect with?

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* 3. When you connect with your healthcare provider, do they involve you, as much as you want to be, in decisions about your care and treatment?

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* 4. Were you able to connect with your provider in a way that met your needs?

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* 5. Please rate your level of agreement with the following statements:

  Strongly agree Agree Neither agree nor disagree Disagree Strongly disagree
I felt comfortable and welcome during my appointment.
My provider explained things in a way that was easy for me to understand.
My health concerns have been taken care of, or are being taken care of.
I trust my healthcare provider/team.

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* 6. How would you rate your overall experience with the Thames Valley Family Health Team?

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* 7. Do you have any other comments you would like to share?

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* 8. In addition to patient surveys, we also look for your feedback through public sessions and quick one-on-one calls, and we would appreciate your input into creating new programs and services. If you are interested in participating in any of these opportunities or sharing how we have helped improve your health, please provide your name and preferred contact method (phone or email) in the space below.

(Alternatively, you can also leave a message at 519-473-0530, ext. 5123 or email patient.experience@thamesvalleyfht.ca.)

Thank you!

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