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Clinic Location: |
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Name: |
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Address: |
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Phone: |
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Fax: |
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Employer Name: |
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Your Title: |
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Your Email: |
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No. of Employees: |
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Employer Primary Contact: |
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Primary Contact No: |
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Employer Secondary Contact: |
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Secondary Contact No: |
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Drug screen results received within 24-72 hours?: |
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Drug screen and physical reporting done in a timely manner?: |
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Work status notes & referrals reported same day?: |
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Bills received timely, accurate and legible?: |
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Clinic appointment availability: |
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Was the staff courteous, polite and professional?: |
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Cleanliness & comfort of clinic: |
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Overall quality of client care: |
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Would you recommend another employer to ACMG?: |
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Do you utilize the 24/7 Riverwalk Urgent Care Clinic?: |
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Are you familiar with our onsite services?: |
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Which clinic do you prefer sending your employee to?: |
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Would you consider our clinic for any future medical services? If Yes please select an answer from the drop down box: |
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Please make recommendations you would like to see to better serve you? |
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Comments: |
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