Did the Receptionist greet you with respect and kindness?

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* 1. Did the Receptionist greet you with respect and kindness?

Did the Medical Assistant listen to you and was attentive to your needs?

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* 2. Did the Medical Assistant listen to you and was attentive to your needs?

Did the Provider have good bedside manners?

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* 3. Did the Provider have good bedside manners?

Did you understand your diagnosis, treatment and follow-up?

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* 4. Did you understand your diagnosis, treatment and follow-up?

Please rate your overall satisfaction with your visit.

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* 5. Please rate your overall satisfaction with your visit.

Please rate the cleanliness of our facility.

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* 6. Please rate the cleanliness of our facility.

Would you recommend Hometown to friends and family members?

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* 7. Would you recommend Hometown to friends and family members?

How would you compare Hometown to other urgent cares you have visited?

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* 8. How would you compare Hometown to other urgent cares you have visited?

Please suggest one thing we could change to make your next visit better.

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* 9. Please suggest one thing we could change to make your next visit better.

Visit ID

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* 10. Visit ID

Visit Date

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* 11. Visit Date

MM/DD/YYYY
Optional contact Information: Please provide your name, phone or email address.

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* 13. Optional contact Information: Please provide your name, phone or email address.

T