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* 1. Which one of our departments did you recently visit at our Farmington location?

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* 2. Were you asked if you had visits with other healthcare providers
since your last visit with us?

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* 3. How would you rate your ease of getting care/making appointments?

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* 4. How would you rate your ability to get medical/dental advice when the office is closed? 

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* 5. How would you rate your satisfaction with your provider/staff? 

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* 6. How would you rate your provider on getting you answers and/or making you feel respected?

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* 7. You may need other services that we do not provide. How would you rate the help/contact information you received from our staff for these services?

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* 8. How are our costs, collections, and explanation of benefits in comparison to other local healthcare providers providing similar services?

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* 9. Will you return to GMHC for care?

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* 10. Will you recommend GMHC to friends/family?

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* 11. Overall, was the facility clean?

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* 12. Are you currently aware of our sliding scale discount?

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* 13. If you answered yes to the last question, Which Federal Poverty Level percentage do you fall within:

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* 14. How long was your wait time in the waiting room?

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* 15. How long was your wait time in the exam room?

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* 16. Do you currently have transportation?

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* 17. Please provide any suggestions or additional feedback.

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* 18. To be entered into our drawing for the survey drawing please provide your name and contact information. (Optional)

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