Your responses to these questions will help us impove the care we provide.

Participation in this survey is voluntary and all you your responces will be kept confidential.

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* 1. Are you completing this survey for yourself or for another person?

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* 2. If you are completing this for someone else, who are you completing this for?

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* 3. Age Range:

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* 4. What is your gender:

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* 5. What city/town do you live in:

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* 6. Where do you see your provider?

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* 7. How did you hear about our clinic?

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