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* 1. Date of Service:

Date

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* 2. What service(s) did you receive? (check all that apply)

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* 3. Please rate your level of agreement with the following statements:

  Strongly Agree Agree Neither Agree nor disagree Disagree Strongly disagree
I received the information or service that I needed
I was served in a timely manner
I was treated with courtesy and respect
Staff was knowledgeable & easy to understand

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* 4. What was your Overall Satisfaction with the service(s) received.

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* 5. How did you hear about HCPH? (Choose all that apply)

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* 6. How can HCPH improve its service(s)?

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