Please rate the following:	Excellent Very Good Good Fair Poor
Convenience of our location
The ease of making your appointment
Length of time waiting at our center
Explanation for extended waiting time
Courtesy shown by our staff
Cleanliness of our center
Thoroughness of treatment you recieved
Attention given to what you had to say
Explanation of treatment given
Explanation of instructions at discharge
Explanation of financial responsibility
Your confidence in the skill of your provider
Personal manner of the provider
Overall quality of care and service given at our center
Would you recommend our center to your family and/or friends?	YesNo
What other comments do you have for our center?

Your Doctor's Name:		Date Seen:
(Optional) Your Name:		Phone #: