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Prescription Refill Request
Patient Review/Feedback
Office and Staff
Ease of scheduling urgent appointments
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5
4
3
2
1
Office environment, cleanliness, comfort, etc.
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5
4
3
2
1
Staff friendliness and courteousness
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5
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3
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1
Total wait time (waiting & exam rooms)
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40 minutes
30 minutes
20 minutes
10 minutes
5 minutes
Provider Experience
Level of trust in provider's decisions
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5
4
3
2
1
How well provider explains medical condition(s)
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5
4
3
2
1
How well provider listens and answers questions
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5
4
3
2
1
Spends appropriate amount of time with patients
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5
4
3
2
1
Comments/Experience
Please tell us about your experience at Princeton Family Care
If you want to be contacted please provide:
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1. Name (Last Name, First Name
2. Telephone
Thank you for Providing Your Valuable Feedback
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