Patient Feedback Form

First Name*
Last (Initial only)*
City/State*
Please rate your overall experience at the allergy clinic?*

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Professionalism of the allergy nurse? *

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1 is Worst, 5 is Best
Cleanliness of the allergy clinic? *

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1 is Worst, 5 is Best
Care provided by the allergy nurse? *

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1 is Worst, 5 is Best
How was the patient education you received from the allergy nurse ? *

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1 is Worst, 5 is Best
How long you have been receiving allergy shots?*

Less than 6 month's6 months to 1 yearMore than a year
How satisfied are you with the allergy immunotherapy you received?*

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1 is Worst, 5 is Best
Have your allergy symptoms improved with immunotherapy?*

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1 is Worst, 5 is Best
Would you recommend the allergy clinic to a friend or a family member?*

YesNo
Any other recommendations or feedback that you would like to leave?
TERMS:

By providing your information, including testimonials, you agree that this information may be used for marketing purposes by our clinic. This includes, but is not limited to, use in promotional materials, on our website, and in other marketing communications. We greatly appreciate your support and contribution to helping others learn about our services.
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