Please provide any positive feedback, constructive feedback, general comments, concerns, or suggestions on a provider (Physician, Nurse Practitioner, Allied Health, Nurse, or Secretary) of the Chatham Kent-Family Health Team.

* 1. Provider (Physician, Nurse Practitioner, Allied Health, Nurse, Secretary) Name:

* 2. Please provide the date of the encounter for which you are providing feedback.

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* 4. Comments:

If you wish to be contacted please provide your demographical information below and a member of the Chatham-Kent Family Health Team Administrative Personnel will be in contact with you. If you wish to remain anonymous please feel free to submit without providing any personal data.

* 6. Contact Information

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