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Health Services Comment Form
Please let us know how we did
A as the highest and E as the lowest.
| Appointment Availability | A B C D E |
| Waiting Room Time | A B C D E |
| Quality of Care | A B C D E |
| Overall Experience | A B C D E |
| What went well during the visit? |
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| What could we do better? |
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| Would you recommend our services to a friend? Yes No |
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| Name (Optional) |
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| Phone (Optional) |
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| Date of Visit (Optional) |
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