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                        Patient Visit Survey
 
Please note that all surveys are kept confidential.
Date of Visit
What provider did you see?
1. How was your overall experience at the time of visit?
Excellant
Good
Fair
Poor
Extremely Poor
2. Please add any comments you wish to explain your evaluation of your experience. What did we do well? What did we do poorly?
3. Would you recommend a friend or relative to our practice?
Yes
No
Maybe
4. How can we improve the quality of service we provided?
 
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