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Patient Feedback Form
Welcome. Please complete this form in as much detail as possible to enable us to attend properly to your request. We respond to all patient feedback unless you ask us not to.
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Name
First
Last
If you want to submit your feedback anonymously, you can leave this field blank
Do you want to provide your Patient Number
*
Yes
No thank you
I don't have one
If you've visited our clinics as a patient, you have been issued a unique patient number that is printed on the patient card you were given. Your baby will have a different number and also have their own patient card.
Please enter your patient number
Please select your country
*
America
Cambodia
India
Philippines
Rwanda
Site Code
The site code tells us where your clinic is located. You can find it on your patient card and it looks like this CL#PH001
Your doctor's name
Tell us the name of the doctor you've seen at our clinic
What feedback would you like to leave
*
General Comments
Praise a staff member
Lodge a complaint
Ask a question
What is the nature of your complaint?
*
My doctor
A staff member
A procedure
Other
Leave your comments below
Tell us who impressed you and why
Details of your complaint
What would you like to know?
Do you want us to get back to you
No thank you
Yes, please call me
Yes, please email me
Please provide a cell number
Please enter your email address
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