Demographics

Patient's Name (Optional):

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* 1. Patient's Name (Optional):

Date of admission:

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* 2. Date of admission:

Doctor's Name (Optional):

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* 3. Doctor's Name (Optional):

Patient's gender:

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* 4. Patient's gender:

Postcode:

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* 5. Postcode:

Age of Patient:

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* 6. Age of Patient:

Who is completing this survey?

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* 7. Who is completing this survey?

Department:

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* 8. Department:

How many days were spent in hospital?

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* 9. How many days were spent in hospital?

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Question Title

* 10. Would you like to join our mailing list to receive our bimonthly patient newsletter “SPH Connect”? The newsletter provides you with information on our safety and quality performance and offers you an opportunity to comment on ways you think we could improve.
Please provide your details below to subscribe.

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