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NG MEDICARE AND CALCUTTA HOPE INFERTILITY CLINIC
Format No. ; NG/FMI16
_ COMPLAINT/SUGGESTION FORM = =
int /Suggestion: « W33 noe Nath Raw
Name of the Compiai
Address Oy
~ Rash Oehert Boome Vp lah Pedag
== Seyescins |" asetesciqgg
[emai Ragen nor oul @ gira! «Cron,
| To Anfticient tl beg Coumbee
ae Pre lene f> PARC ye oD ia,
he Path once
(ronmedtetabs bo ur
| pate; VN Ua A wo tn tame —
Patient's IDNo _ | VisitDate: — ‘Report Date:
pr ED SPIT IYorfacrs |" Vafortasts
Patient's Name: Sex: od
Meant Raw - Me bis ys /
wo Bo, Rarh Paneur hos Rol Radifores
Referred Doctor;
_ SSB
Remarks: She Ts poor CAMS penttenen Paltenr,
Se had te wath a long Ame tin bing.
She pewwesk fo Mnewesse He num PY
Counsemg. So TRH Shite Ppeeple te wih
| hope te walk any lengen
‘Complaint Suggestion Reviewed By: bo» j>o
Date: 16 L0% JAKoh
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Dont jot Biighang “Road
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wha A: Svdsskna Roy tea
am SHES:
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Sera:
6G: Woe has ne Complam he ie psweoded
te anpenge oh Fie th play beara
dev deuer-
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