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* 1. Today's Date:

Date

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* 2. Type of Appointment

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* 3. Did you get your appointment as soon as you needed it.

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* 4. Which Provider was your appointment with?

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* 5. Did the office staff treat you with dignity and respect

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* 6. Were you seen within 15 minutes of your appointment time

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* 7. Did the nurse treat you with courtesy and respect

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* 8. Did your physician listen carefully to what you had to say

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* 9. Did your provider spend enough time with you during your appointment

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* 10. Physicians and nurses care for me as a "whole person" rather than just the illness for which I present during my visit.

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* 11. My physician coordinates my care appropriately with other physicians/specialists and required testing services

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* 12. Please provide any additional comments about your visit

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