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Patient Satisfaction Survey

Page One

We are committed to ensuring that you are satisfied with the care and services you receive at our practice. Please let us know what you think about your experience with us. If there is a particular person who stands out, please provide the name, if you can. A "*" indicates a response is required.
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3. Please rate your satisfaction with the overall performance of the phone scheduling staff. *This question is required.
4. Please rate your satisfaction with the overall performance of the reception staff who helps check you in at our office. *This question is required.
5. Please rate your satisfaction with the overall performance of the nurse(s) who helped you. *This question is required.
6. Please rate your satisfaction with the overall performance of the medical assistant(s) who helped you. The medical assistants are typically the staff who room patients and do labs and vaccinations. *This question is required.
7. Please rate your satisfaction with the overall performance of the provider who saw your child. *This question is required.
9. How likely is it that you would recommend our practice to your family members, co-workers, and friends?
12. If you would like someone from our office to contact you regarding your comments please enter your name and telephone number in these boxes and we will be in touch as soon as possible.
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