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* 1. Date you were here

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* 2. Why did you choose to come to the Medical Clinic?

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* 3. How did you hear about us?

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* 4. Why are you here today?

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* 5. Please rate our customer service and facility?

  Excellent Good Poor
Check In/Check Out
Nurses
Doctors
Cleanliness
Appearance

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* 6. How satisfied are you with the ability to access care (appointment availability)?

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* 7. How well were you able to understand information provided by the healthcare provider? 

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* 8. Are the clinic hours good for you?

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* 9. Which of the following do you like?

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* 10. Overall, how was our service?

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* 11. If it is poor can you tell us why?

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* 12. How long were you at the clinic today?

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* 13. Other comments:

T