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MEMBER COMMENTS FORM

DETAILS OF MEMBER

Name of Member :
Company Name :
Membership Number :
Office Telephone Number :
Handphone Number :
Email Address :

DETAILS OF COMMENT / FEEDBACK / COMPLAINT

Please state your comment / feedback / complain here. We will appreciate it if you can also provide as much details such as time, date, place, persons involved, etc. for the purpose of recognition and improvement.

DETAILS OF CLINIC / HOSPITAL (if applicable)

Clinic / Hospital Name :
Doctor's Name :
Clinic / Hospital Address :
Date and Time of Visit :

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