Family Doctor agreement submit form

Benefits of having a Family Doctor:1,Free review of checkup reports once a year.2,Free prescription fee for medication refills.3,Free follow up calls.4,Priority given for appointments and referral services.

Q1:Would you recommend this FM physician to your friends / family?

Q2:Are you satisfied with your visit today?

Satisfied
Unsatisfied

Q3:Do you agree to have this doctor become your PCP doctor?

Agree
Disagree
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Family Doctor agreement submit form
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