| Your Name (Optional) |
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| Address (Optional): |
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| Diagnosis (Optional): |
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| Date of service: |
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Provider Name: (Doctor / Therapist) |
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Please describe your experience: |
How satisfied were you with the amount
of time the doctor spent with you?
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| How satisfied were you with the information
you received about your condition or treatment? |
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| How satisfied were you with the way
the doctor listened to what you had to say? |
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| How satisfied were you with the doctor's
ability to answer your questions in a way you could understand? |
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| How satisfied were you with the explanation
given by the doctor or nurse on what to do if problems or symptoms
continue, get worse or come back? |
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| How satisfied were you with the help
the doctor gave you to make changes in your habits or lifestyles
that would improve your health or prevent illness? |
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| How satisfied are you that your Doctor
was informed and up-to-date about the care you received from our
Office? |
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| Using any number from 1-10 where 10
is the Best Doctor possible, and 1 is the Worst Doctor possible,
please press the number that you would rate this doctor now. |
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| How likely are you to refer this doctor
to family and friends? |
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| How satisfied were you with your ability
to make an appointment? |
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| How satisfied were you with the amount
of time you waited at the doctor's office, including both the time
you spent in the waiting room and in the exam room? |
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| Comments or Suggestions: |
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