1. Default Section

* 1. Did you wait longer than 20 minutes to be seen?

* 2. Was your visit the result of a scheduled appointment?

* 3. Was the Specialist professional and courteous?

* 4. If No, please briefly explain:

* 5. Did the Specialist answer your questions thoroughly?

* 6. If No, please briefly explain:

* 7. How can SHA better serve you?

* 8. Tenant Name

* 9. Specialist Name

* 10. Date of Visit

Date
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* 11. Reason for visit?

T