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Hospital Visited:
 
 
 
Provider:
 
 
How would you rate the following?
Poor Fair Average Above Average Excellent
Overall care received in the Emergency Department:
Communication of plan of care by provider:
Clarity of discharge instructions:
Competency and courtesy of provider:
 
 
 
How likely are you to recommend this Emergency Department?
 
Extremely
 
Very
 
Moderately
 
Slightly
 
Not at all
 
 
 
Comments/Suggestions:
   
 
 
 
Would you like to be contacted regarding this survey?
 
Yes
 
No
 
 
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First Name : 
Last Name : 
Phone : 
 
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