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* 1. How easy or difficult was it to schedule your appointment at a time that was convenient for you?

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* 2. How was the cleanliness and appearance of the clinic during your visit?

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* 3. How friendly was the receptionist when you arrived at our office?

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* 4. How friendly was the staff taking your child's vital signs?

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* 5. Who was the provider seeing your child for this visit? (leave blank if not applicable)

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* 6. How well did your provider answer your questions and explain treatment plan?

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* 7. Overall, how would you rate the care you received from your provider?

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* 8. How friendly was the staff administering treatments and/or vaccines in the exam room?

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* 9. Overall, when you have a scheduled appointment, how often do you wait more than 30 minutes to see your provider? (Wait time includes time spent in the waiting room and exam room.)

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* 10. If wait time seemed unreasonable, where did you feel the wait was too long? (select all that apply)

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* 11. How satisfied or dissatisfied were you with the amount of time your provider spent with you addressing your needs?

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* 12. How likely is it that you would recommend Argenal Pediatrics to a friend or colleague?

Not at all likely
Extremely likely

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* 13. Is there anything we could have done to improve your last visit? (Please do not leave blank. Your comments help us learn the most how to improve)

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* 14. Please fill in the blanks in regards to Argenal Pediatrics:

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* 15. Please provide the following information (optional)

T