Dear Patient: According to our records, you recently visited the provider named above. We will
appreciate if you please tell us your opinion about the service you received from this provider. Your responses will be kept strictly confidential. Thanks for your help. PLEASE RATE THE FOLLOWING: Excellent 5 / Very Good 4 / Good 3 / Fair 2 / Poor 1 / Does not Apply N/A.
F. YOUR OVERALL SATISFACTION WITH