Dear Patient:

 We are committed to providing the highest quality care and service. We depend on you, the patient, to tell us how we are doing and if there are any areas that need improvement.

 Please take a few minutes today to complete this survey about your last visit with your DOCTOR/CLINICIAN whose name is shown in the box above. If the patient is a child or cannot complete the survey, a family member may complete it for him or her. For your convenience, the survey can be completed and returned in the postage-paid return envelope.

We want your honest and candid opinions. Please be assured that this survey is completely confidential and that your responses will remain anonymous.

 Your feedback is valuable and I appreciate you taking the time to respond. If you have any questions or concerns about this survey or the care you received, please call our Hotline at 702-932-8537.