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Thank you for completing this short survey about your most recent visit to our office. Your insights will assist us in improving our services.

Patient Survey

1. Were you treated courteously by the doctor at your most recent visit? Yes No

2. Were you treated courteously by the staff? Yes No

3. Did you feel that the doctor was concerned about you? Yes No

4. Was the office environment clean and pleasant? Yes No

5. Would you return to this office for more treatment? Yes No

6. Was your experience...

7. Would you refer this office to friends and family? Yes No

8. Were you instructed on what to expect following treatment? Yes No

9. Could we have done anything to make your visit more pleasant? Yes No

Please Explain

10. Additional Comments

If you would like to be contacted regarding this survey, please enter your name and phone number.

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