Provide Us with Your Names

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* 1. Provide Us with Your Names

Your phone number?

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* 2. Your phone number?

Name of the Facility (clinic,hospital etc)

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* 3. Name of the Facility (clinic,hospital etc)

Give us the location/town where the facility is situated

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* 5. Give us the location/town where the facility is situated

Enter the date when you visited the medical practitioner?

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* 6. Enter the date when you visited the medical practitioner?

Date / Time
What is your chief Complain/ Why do you think the personnel is a Quack

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* 7. What is your chief Complain/ Why do you think the personnel is a Quack

T