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Nothing is more important to us than your satisfaction. Our physicians and office staff are here to help you. Please let us know how your visit was today.

* = Required Fields
Date:
*
Physician/Nurse Practitioner/Physician Assistant/Midwife/Physical Therapist you/your child saw today:
*
How long have you been a patient/parent at this practice?




How satisfied are you with the following:

Visit overall

Availability of appointment

Scheduling of appointment

Scheduled with your choice of physician/nurse practitioner/physician assistant/midwife/physical therapist

Appearance of office

Wait time in office

Time with physician/nurse practitioner/physician assistant/midwife/physical therapist

Office staff friendly and courteous

Physician/nurse practitioner/physician assistant/midwife/physical therapist answered all your questions

Billing procedures

Ease and efficiency of checking in

Ease and efficiency of checking out



What specifically can we do to make your next visit better?


Did we do anything in particular that enhanced your visit? (Please include names of any employees so they can be thanked personally)


If you have any comments or questions you would like to share regarding your visit with us, please list them below:




Name:
Phone:
Email Address:
*
Would you like someone to call you about your visit? Yes



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