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Complaint Form
Customer Complaint Form
Thank you for assisting us to serve you better and improve our services, please note that your complaints are valid and relevant to our services. Please fill this form and we will give you a feedback in not more than three working (3) days.
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Complaint
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Preferred Contact Method (Phone, Email, WhatsApp etc)
Phone, Email or WhatsApp
INFORMATION/COMPLAINT ON TEST DONE/SERVICES PROVIDED (PLEASE TICK THE BOX)
RECEPTION
PHLEBOTOMY
LABORATORY
ULTRASOUND
MRI
MAMMOGRAM
X-RAY
CT
CERVICAL
ASSESSMENT
OTHERS
COMPLAINT(S):
Is any documentation attached?
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Your ticket for the: Complaint Form
Title
Complaint Form
USD
