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*dapted from #linic and +ndoscopy Patient #are +&perience ,uestions -../% 0innesota Gastroenterology% P.*. #opyright 1 -..2 by the *G* Institute
1xa'ple Practice | Address 1 | Address 2 | City, State ZIP | Telephone | Fax /$ Please indicate the extent to %hich you a&ree or disa&ree %ith each of the follo%in& state'ents$ (se a scale of 1 to ), %ith ) *ein& Stron&ly A&ree and 1 *ein& Stron&ly 2isa&ree$ If an ite' is not related to your care, choose ,#A$ Stron&ly So'e%hat So'e%hat Stron&ly 2isa&ree 2isa&ree ,eutral A&ree A&ree ,#A -1. -2. -/. -0. -).
0y physician'provider spent ade3uate time with me. The service'care provided was valuable to improving my health. The educational information I received was helpful. I clearly understand the ne&t steps in my plan of care. 0$ If la* %or3 %as done, did you receive your la* results in a ti'ely 'anner follo%in& your office visit4 ! "es ! ,o ! ,ot applica*le
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5ould you return to see this physician#practitioner for further care4 ! "es ! ,o
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2id any specific staff 'e'*er stand out4 If yes, %ho and %hy4
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5as there any aspect of your care that could *e i'proved4 If yes, please explain$
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Please tell us %hat you li3e *est a*out the care you received$
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Please tell us %hat you li3e least a*out the care you received$