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* 1. Date of ServiceĀ 

Date / Time

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

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

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* 4. The staff was friendly and helpful

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* 5. I was served in a timely manner

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* 6. The health center was easy to locate

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

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* 8. The services I received met my cultural needs

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* 9. The services I received met my particular needs

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

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* 11. Please leave any additional comments below. 

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