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Adult Medical History
Comment Form
Demographics
Medication Refill Request Form
Comment Form
Ease of Scheduling
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Excellent
Very Good
Good
Poor
Courtesy of Staff
*
Excellent
Very Good
Good
Poor
My Doctor Listened
*
Excellent
Very Good
Good
Poor
Problem Addressed Well
*
Excellent
Very Good
Good
Poor
Cleanliness of Office
*
Excellent
Very Good
Good
Poor
I will refer friends and family
*
Definitely
Maybe
No Thanks
May we know your name?
Other Comments:
These comments go directly to the doctor's desktop.
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