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* 1. During your visit today, which provider did you see? 

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* 2. Did the provider explain things in a way that was easy to understand?

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* 3. When you contacted the provider’s office to get an appointment for your child, did you get an appointment as soon as your child needed?

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* 4. How likely are you to recommend our office?

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* 5. Is there someone you would like to acknowledge for recognition or self-improvement? 

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* 6. What could we have done to make your experience in our office better?

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