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Feedback Form

Our feedback form serves as a vital tool for you to express how we can improve. Please refrain from submitting personal medical information through this form or attempting to reach your healthcare provider. 

Feedback Form

I am a:
Patient
Family Representative
Other
This is a:
Suggestion
Compliment
Concern
Complaint
I would like to be contacted by management regarding my submission:
Yes
No

IMPORTANT: This form is NOT for personal or patient requests.


Do NOT use this form to:

• Ask about your health, medical record, or results

• Request appointment details (date, time, location)

• Ask us to contact your doctor


These requests will NOT be answered.


Please contact our office at 613-687-7641.

Single choice
I understand this form cannot be used for personal or patient requests and I must contact the clinic directly
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