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1. Did you have trouble locating our office?
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No   
1a. If yes, please explain:
2. When I called the office during regular office hours, I received the help or advice I needed.
Yes   
No   
3. If I had to leave a message, I received a call back that same day.
Yes   
No   
3a. If no, what was the unreturned call regarding?
4. The front office staff met and greeted me promptly and courteously.
Yes   
No   
5. The nursing staff greeted me promptly and courteously.
Yes   
No   
6. The nurses spent an appropriate amount of time with me to understand and communicate my medical needs.
Yes   
No   
7. How long did you have to wait to see the provider?
8. The provider listened to me and my problems and showed respect and concern for what I had to say
Yes   
No   
9. The provider explained things in a way I could understand.
Yes   
No   
10. The provider spent enough time with me at this visit to discuss the problem I came in for.
Yes   
No   
11. Which provider (doctor) did you see?
12. When I checked out, the staff member collected my payment, or explained the insurance billing if needed.
Yes   
No   
13. If I received a referral to a specialist at my visit, it was handled in a timely manner and to my satisfaction.
Yes   
No   
14. I was satisfied with how quickly the office was able to arrange an appointment for me.
Yes   
No   
15. I would recommend your facility to others.
Yes   
No   
16. The rating I would give the staff and the provider for this visit at your facility.
Poor   
Fair   
Good   
Excellent   
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