*1.What is the nature of your feedback?(Required.)

Complaint

General Feedback

Suggestion

Praise

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

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

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

5.Have our services been useful to you?

Yes, very useful

Somewhat useful

Not very useful

Not useful at all

6.Please provide any additional comments or feedback.

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