* 1. Which provider did you see today?

* 2. I am able to get through to the office on the phone during office hours

* 3. In the last 12 months, when you phoned your dentist's office after regular office hours, how often did you get an answer to your question as soon as you needed?

* 4. How convenient was the appointment time you were able to get?

* 5. How easy is it to schedule urgent appointments with your dentist?

* 6. How courteous and helpful was the receptionist when you arrived at our office?

* 7. How friendly was the clinical staff during your visit?

* 8. Overall, how often do you wait more than 15 minutes to see your dentist or hygienist? (Wait time includes time spent in the waiting room and exam room.)

* 9. How satisfied or dissatisfied were you with the amount of time your dentist or hygienist spent with you addressing your needs?

* 10. Were your needs met at this visit?

* 11. Did anyone talk to you about the medication you take?

* 12. Did your provider talk to you about your health goals?

* 13. Were you asked if you had visits with other health care providers since your last visit?

* 14. Did anyone help you make an appointment with a specialty provider if necessary?

* 15. Have we ever given you information about FMC being your medical home?

* 16. Have we ever helped you find other community resources you might need that FMC does not provide?

* 17. Do you feel that what you pay for your care is reasonable?

* 18. May we contact you for further input regarding your cost of care?

* 19. Would you recommend FMC to your friends and family?

* 20. Do you have any comments or suggestions?

* 21. What is your race?

* 22. What is your ethnicity? (Please select all that apply.)

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