Date of Service

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* 1. Date of Service

Reason for visit? (check all that apply)

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* 2. Reason for visit? (check all that apply)

How did you receive service?

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* 3. How did you receive service?

Are the office hours convenient?

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* 4. Are the office hours convenient?

Were you satisfied with the information or service that you received?

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* 5. Were you satisfied with the information or service that you received?

Were you served in a timely manner?

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* 6. Were you served in a timely manner?

Was the staff respectful and well informed?

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* 7. Was the staff respectful and well informed?

Would you give the Health Department facilities a good rating? (cleanliness, signs, parking, etc.)

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* 8. Would you give the Health Department facilities a good rating? (cleanliness, signs, parking, etc.)

If you would like to be contacted to discuss any concerns, please provide contact information.

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* 9. If you would like to be contacted to discuss any concerns, please provide contact information.

Comments/Suggestions

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* 10. Comments/Suggestions

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