* 1. Date of ServiceĀ 

Date / Time

* 2. Service(s) you received today (check all that apply):

* 3. The office hours and appointment times met my needs

* 4. The staff was friendly and helpful

* 5. I was served in a timely manner

* 6. The health center was easy to locate

* 7. I am completely satisfied with today’s services

* 8. The services I received met my cultural needs

* 9. The services I received met my particular needs

* 10. Would you like to be contacted? If so, please leave your contact
information.

* 11. Please leave any additional comments below. 

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