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e-Feedback Form 电子反馈表

Are you giving feedback on behalf of a patient
是否代表患者提供这项反馈？*

Salutation
称呼*

Sender's Name (on behalf of patient)
发件人的姓名（代患者）*

Sender's contact number (Local number)
发件人的联络号码（本地）

Email Address
电邮地址*

Salutation
称呼*

Patient's Name (as per NRIC)
姓名（患者）*

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）*

Email Address
电邮地址*

Polyclinic Visited
诊疗所

Date of Visit
就诊日期

Feedback
反馈内容*

Max 5000 characters
(限5000字)

Would you like us to contact you regarding your feedback?
是否要我们联系你？*

Captcha *

Submit Cancel

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2021/10/18