Please answer ALL questions

We would like to know how you feel about the services we provide so we can make sure we are meeting your needs. Your responses are directly responsible for improving these services. All responses will be kept confidential and anonymous. Thank you for you time.

Your Age

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* 1. Your Age

Your Sex

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* 2. Your Sex

Your Race/Ethnicity

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* 3. Your Race/Ethnicity

Appointment or Walk-in?

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* 4. Appointment or Walk-in?

Name of Provider

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* 5. Name of Provider

Ease of Getting Care: Ability to get in to be seen

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* 6. Ease of Getting Care: Ability to get in to be seen

Ease of Getting Care: Hours Center is open

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* 7. Ease of Getting Care: Hours Center is open

Ease of Getting Care: Convenience of Center's location

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* 8. Ease of Getting Care: Convenience of Center's location

Ease of Getting Care: Prompt return on calls

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* 9. Ease of Getting Care: Prompt return on calls

Waiting: Time in waiting room

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* 10. Waiting: Time in waiting room

Waiting: Time in exam room

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* 11. Waiting: Time in exam room

Waiting: Waiting for tests to be performed

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* 12. Waiting: Waiting for tests to be performed

Waiting: Waiting for tests results

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* 13. Waiting: Waiting for tests results

Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Listens to you

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* 14. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Listens to you

Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Takes enough time with you

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* 15. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Takes enough time with you

Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician, Assistant, Nurse Practitioner - Explains what you want to know

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* 16. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician, Assistant, Nurse Practitioner - Explains what you want to know

Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Gives you good advice and treatment

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* 17. Staff Provider: Physician, Behavioral Health Specialist, Dentist, Physician Assistant, Nurse Practitioner - Gives you good advice and treatment

Staff Provider: Nurses, Medical Assistants and Dental Assistants - Friendly and helpful to you

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* 18. Staff Provider: Nurses, Medical Assistants and Dental Assistants - Friendly and helpful to you

Staff Provider: Nurses, Medical Assistants and Dental Assistants - Answers your questions

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* 19. Staff Provider: Nurses, Medical Assistants and Dental Assistants - Answers your questions

Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Friendly and helpful to you

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* 20. Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Friendly and helpful to you

Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Answers your questions

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* 21. Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Answers your questions

Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Interpretation/Translation services

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* 22. Staff Provider: (Health Educator, Case Manager, Outreach-Eligibility, and all others) - Interpretation/Translation services

Payment: What you pay

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* 23. Payment: What you pay

Payment: Explanation of charges

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* 24. Payment: Explanation of charges

Payment: Collection of payment/money

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* 25. Payment: Collection of payment/money

Facility: Neat and clean building

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* 26. Facility: Neat and clean building

Facility: Ease of finding where to go

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* 27. Facility: Ease of finding where to go

Facility: Comfort and Safety while waiting

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* 28. Facility: Comfort and Safety while waiting

Facility: Privacy

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* 29. Facility: Privacy

Confidentiality: Keeping my personal information private

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* 30. Confidentiality: Keeping my personal information private

The likelihood of referring your friends and relatives to us

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* 31. The likelihood of referring your friends and relatives to us

Please provide any SPECIFIC DETAIL for any item rated 3 or below:

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* 32. Please provide any SPECIFIC DETAIL for any item rated 3 or below:

Do you consider this center your regular source of
care?

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* 33. Do you consider this center your regular source of
care?

What do you like best about our center?

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* 34. What do you like best about our center?

What do you like least about our center?

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* 35. What do you like least about our center?

Do you have any suggestions for improvement?

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* 36. Do you have any suggestions for improvement?

Would you like to be contacted? If yes, please provide information for desired contact method:

Name: ____________________________________________________________________

Email: _____________________________________________________________________

Telephone: _______________________________________________________________

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* 37. Would you like to be contacted? If yes, please provide information for desired contact method:

Name: ____________________________________________________________________

Email: _____________________________________________________________________

Telephone: _______________________________________________________________

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