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* 1. What is the nature of your feedback?

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* 2. Please describe the situation, including any people involved.

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* 3. What are your recommendations on how we can improve?

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* 4. How would you rate the overall quality of the healthcare services provided? One a scale from 1 to 10 with 1 being poor and 10 being very impressive

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* 5. Have our services been useful to you?

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* 6. Please provide any additional comments or feedback.

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