Our records indicate that your child has visited our clinic in the last 6 months, and we would like you to tell us about their care.  We are committed to providing your child with the best quality health care available, and your input will help us to achieve this goal.  This brief survey should only take about 10 minutes or less of your time.

Your Privacy is Protected.
Your Participation is Voluntary.

Question Title

* 1. Our records show that your child got care from the provider named below in the last 6 months.  Please select provider:

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