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e-Feedback Form 电子反馈表
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e-Feedback Form 电子反馈表
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e-Feedback Form
Are you giving feedback on behalf of a patient
是否代表患者提供这项反馈?
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Salutation
称呼
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Sender's Name (on behalf of patient)
发件人的姓名(代患者)
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发件人的联络号码(本地)
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电邮地址
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Salutation
称呼
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Mr
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Patient's Name (as per NRIC)
姓名(患者)
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Patient's NRIC (last 3 numerical digits and 1 alphabet)
身份证(患者)(后3个编号,1个字母)
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Contact Number (Local number)
联络号码(本地)
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电邮地址
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诊疗所
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Bukit Batok Polyclinic / 武吉巴督综合诊疗所
Bukit Panjang Polyclinic / 武吉班让综合诊疗所
Choa Chu Kang Polyclinic / 蔡厝港综合诊疗所
Clementi Polyclinic / 金文泰综合诊疗所
Jurong Polyclinic / 裕廊综合诊疗所
Pioneer Polyclinic / 先驱综合诊疗所
Queenstown Polyclinic / 女皇镇综合诊疗所
Date of Visit
就诊日期
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反馈内容
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(限5000字)
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是否要我们联系你?
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2021/10/18