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Village Family Clinic & Wellness Center
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#2 NEW PATIENT- ADHD assessment
*Binge eating disorder assessment
*FOLLOW-UP FORM: Anxiety
*FOLLOW-UP FORM: Depression
MDQ follow-up
Medication renewal form
*FOLLOW-UP FORM: ADHD
Patient survey
Patient survey
How would you rate your level of satisfaction with our communication time?
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0 = not satisfied at all 10 = extremely satisfied
How has your experience been with online scheduling?
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I have not scheduled an appointment online yet
1 = very bad 10 = excellent
How likely are you to refer a friend, colleague, or family member to our office?
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1 = extremely unlikely <br/>5 = very likely
Would you be interested in a monthly ADHD newsletter?
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No
Would you be interested in attending an ADHD workshop in the office?
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Yes
No
Do you feel that our website is easy-to-use?
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1= not at all 5 = it is very easy to use
Do you have any questions or comments for our office?
* Required field
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