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Confidential Patient Satisfaction Survey

    Clinic location
    Date

    How would you rate the check in process?


    About how long did it take for a clinical assistant to start the check-in process?


    About how long did it take for the provider to start the visit after you were checked in?


    Overall, how satisfied were you with your visit?


    Do you think $10 minimum medical copay is appropriate?



    Additional Comments (optional)

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