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Customer Feedback Form
Do you have a compliment or concern?
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Compliment
Concern
What type of compliment are you providing?
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Device Usefulness
Skill of the Clinician
Staff Demeanor
Other
What type of concern are you providing?
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Appointment
Billing
Device Usefulness
Skill of Staff
Delayed Refund
Device or Treatment
Facility
Overall Experience
Other
Who was the clinician you would like to compliment?
Are you the patient or an individual representing the patient:
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Patient
Representative representing the patient
First Name (Representative):
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Last Name (Representative):
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Patient's First Name:
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Patient's Last Name:
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Patient's Primary Insurance:
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Patient's Date of Birth:
Patient's Street Address 1:
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Patient's Street Address 2:
Patient's City:
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Patient's State:
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Patient's Zip Code:
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Email Address:
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Phone Number:
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Date of Service:
Hanger Clinic location the compliment or concern is regarding:
(Please add street, city, state of location)
What service/product was provided to you when visiting the Hanger Clinic location?:
Message:
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