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Name:
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Email Address:
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Home address:
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Home Phone #:
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Work Phone #:
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Insurance:
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Who was your Physician?
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What location did you visit?
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Did you find our office location convenient?
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How did you hear about us?
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Please use the following scale to answer the questions below:
5 = Excellent | 4 = Very good | 3 =
Average | 2 = Poor | 1 = Very poor
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How would you rate our switchboard and telephone service?
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Did you find it easy to make an appointment?
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Was our staff helpful?
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Did the doctor clearly explain the problem and the treatment he prescribed?
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Did you feel that the doctor was truly concerned for your well-being?
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Did your physician spend adequate time with you during your visit?
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Did you feel that your check out and bill payment was courteous and efficient?
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Was the staff helpful in helping you with your insurance coverage?
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Did our medical assistants make you feel comfortable?
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Do you feel you received the highest quality of care from your physician?
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Please rate your overall experience and quality of care provided by OOC?
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What was your wait time?
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How many miles did you travel to reach our office?
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Would you recommend OOC to your family and friends?
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If you answered no, please explain:
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Do you have any comments or recommendations on how we might serve you
better?
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Would you like to be added to our Mailing List?
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