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1. Service you accessed today:

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2. Location you were seen in today:

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3. How would you rate the ability to get an same day appointment when you need one?

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4. How would you rate the ability to get an appointment when you need one?

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5. How would you rate the provider's office with sending you reminders between visits?

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6. How would you rate calling the office, how helpful and courteous was the person who assisted you on the phone?

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7. How would you rate the amount of time your provider spent with you?

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8. How would you rate how well did the clinical team explain your care to you?

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9. How would you rate the ability to understand and follow your provider's instruction regarding self-care, taking medications as prescribed, treatment plans and follow-up care you received from specialist

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10. How would you rate our wait time? Wait time includes time spent in the waiting room and exam room. How often did you see this provider within 20 minutes of your appointment time?

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11. How would you rate how often anyone on the clinical team talk with you about specific goals for your health?

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12. How would you rate how often anyone on the clinical team ask you if there are things that make it hard for you to take care of your health?

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13. How would you rate the hours of operation of the clinic?

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14. Overall, how would you rate your experience with us?

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15. How would you rate how likely are you to recommend our practice to a friend or love one?

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16. Please write any comments, questions, or concerns you have regarding your service experience.

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17. Patient Race

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18. Patient Ethnicity

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19. Date

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