* (required)

Name:*
Date:
I am returning this card as my comments for:
First & last name of physician or support staff member:
Department:
  Poor Fair Good Very Good Excellent
1. Length of time waiting at the office:*
2. Time spent with the physician/healthcare professional you saw:*
3. The personal manner (courtesy, respect, sensitivity, friendliness) of: *
 a. physician/healthcare professional you saw
 b. nursing staff
 c. reception staff
Comments:
Phone number where we could reach you if we have any questions:
           
            
 
 
 
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