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Patient Satisfaction Survey

Please take a moment and fill out the form below.

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While in the facility, do you feel your privacy was protected?
Yes No

Did you witness staff members washing their hands?

Yes No

Were you provided clear information about your procedure?
Yes No

Did you understand the information provided?
Yes No

Did you feel you were given enough time to ask questions?
Yes No

Please feel free to express any specific complaints or concerns in the space below: