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Concerns, issues, suggestions and comments for Renal Patient & Family Advisory Council (PFAC)

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* 1. Date:

Date

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* 2. I am an In-Centre dialysis patient (if not skip to question 4):

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* 3. I am an In-Centre dialysis patient on (click on all that apply, then skip to question 5)

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* 4. I am seen in:

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* 5. Please detail your concern:

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* 6. OPTIONAL:  Please include your contact info:

0 of 6 answered
 

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