It is our goal to give you the best possible medical care.  To do so, it is important that we know your thoughts about the care you are receiving.  We need to know what we are doing right and in what areas we can improve.  Your comments will be strictly confidential.  Thank you!

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* 1. Date your procedure was performed:

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* 2. Type of procedure:

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* 3. Please check your answer to rate each of the following experiences:

  Agree Disagree N/A
My admission process was reasonable
The time I spent waiting was reasonable
I felt comfortable having my procedure done with local anesthesia
I felt comfortable in the chair during the procedure
I feel my post-op instructions and discharge were appropriate and efficient

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* 4. Would you recommend our facility to others?

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* 5. What did you like least?  How can we improve?

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* 6. Additional Comments:

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* 7. May we contact you for permission to use your patient survey as a testimonial?

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* 8. Name (optional):

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* 9. Telephone Number (optional)

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