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Capitol Ear, Nose and Throat
3100 Blue Ridge Road, Suite 201
Raleigh, NC 27612
Tel:(919) 787-1374
Fax : (919)
787-8870
www.capitolent.net
Date: __________________
Patient Name: _____________________________________________________
Date of Birth: ___________________
Name (if different than patient): ________________________________________
Relationship to patient: ______________________________________________
Contact Phone: _________________
Description: ______________________________________________________
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Suggestion for improvement in service and/ or what you feel we should do:
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Thank You ! Your suggestion is our opportunity.
*********************************** For Office Use Only ***********************************
Received by: _______________________________________________________
Date Received: __________________
Action: ____________________________________________________________
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Instructions
1. Print this form, then fax or mail it.
2. Fax (919) 787-8841
3. Mail Address: Capitol Ear, Nose & Throat
3100 Blue Ridge Road, Suite 201
Raleigh, NC 27612