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Patient Name:

Phone Number: *

Doctor's Name: *

How did you hear about us?:

Were you referred to Northwoods?:

Yes

Who may we thank for the referral?:

Survey Item:

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How was your experience scheduling the appointment?
Are you satisfied with our front desk staff?
Are you pleased with our nursing staff?
How well did our Urologists care for you?

How long did you wait?:

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