Customer Complaint Form
First Name
Last Name
Phone
Email
Please kindly write your complaint*
Include much details as possible in order to investigate
How satisfied are you with...
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
The Doctor treated you
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
The Nurse treated you
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
The Reception or Other Staff treated you
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
How satisfied are you with...
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
The Location
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
The Facilities offered
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
The Parking facilities
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
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