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NL Health Services - Patient Relations Feedback Form

Feedback Form
Please review the privacy and confidentiality statement for more information about the collection and use of the information provided through this form. By completing this form, you are acknowledging that you have read this statement and are aware of the purpose and use of the information you provide. 
Name *This question is required.
Select the option that best describes you
Patient information 
Patient name *This question is required.
Geographic area

Select the geographic area most applicable to your feedback
Preferred method of contact *This question is required.
Contact information
An email address or phone number is required. *This question is required.
Type of feedback

Select the type of feedback you are sending
To properly review and provide a response to feedback, we work with the patient, or an authorized representative. Please refer to what to expect when you share your feedback.
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