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Please answer the following questions based on your most recent experience with our clinic

Your Appointment Date *Please select your practitioner *

Please rate how strongly you would agree with the following statements" -2 -1 0 1 2 -2 -1 0 1 2 -2 -1 0 1 2 -2 -1 0 1 2 -2 -1 0 1 2

My practitioner was timely with the start and end of my appointment -2 -1 0 1 2

My practitioner addressed my needs and actively listened to any concerns I had about treatment -2 -1 0 1 2

My practitioner laid out a clear treatment plan or discussed measurable outcomes -2 -1 0 1 2

The space was clean and well-maintained -2 -1 0 1 2

The staff with whom I interacted greeted me and were helpful and polite -2 -1 0 1 2

Please tell us anything else about your patient experience today

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