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* 1. Date:

Date

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* 2. Name of Clinic:

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* 3. Which provider did you see today?

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* 4. Did the Provider listen to what you had to say?

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* 5. Did you understand what the Provider was explaining to you?

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* 6. Did you see your Provider wash their hands or use hand sanitizer?

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* 7. Overall, are you satisfied with care you received?

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* 8. Was the clinic clean?

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* 9. Was the clinic comfortable?

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* 10. Would you like to be contacted for a follow-up based on todays visit?

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* 11. How would you like to be contacted?

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* 12. Contact Phone Number:

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* 13. Mailing Address:

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* 14. Additional Comments/Any specific recommendations based on today's experience:

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