Help us to serve you better

Please answer the following questions to help us serve you better.

Please complete a survey

Demographic and visit information.

1. Please provide the following information so that we may follow up with you regarding any concerns.Thank you. (optional)

Your Name :
Your Email :
Phone Number :

* 2. Please enter the date of your encounter (office visit).

Date of Service :

3. Please provide the name of the Healthcare provider you saw during this encounter.

4. The receptionist was friendly and helpful.

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5. The waiting area was clean and comfortable.

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6. The time spent in the waiting area prior to seeing your Medical Provider was appropriate.

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7. The nurse/medical assistant was courteous and helpful.

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8. You would recommend the Medical Provider to your family and friends.

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9. You are pleased with your overall experience with our Clinic.

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10. Please provide any additional comments or suggestions.

11. How did you hear about us ?

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12. Rate this website

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