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FAQ
Feedback
Quick Start Guide
Instructions
Submit Feedback
Report an issue or experience
Email Address (for Follow Up) *
Email Address
Email field completed
Phone Number *
Phone Number
Phone number field completed
Type of Feedback/Issue *
Site Performance
Support Request
General Feedback
Improvement Suggestion
Medical/Safety Concern
Feedback type selected
About You
Relationship to person who used screener: *
Describe your relationship to the occasion for feedback, complaint or adverse event.
Select...
I am a Patient
I am a Healthcare Provider
I am a Family Member
I am a Friend / Other
Relationship field completed
Name *
Age *
Gender *
Select...
Male
Female
Non-Binary
Email
(for follow-up)
*
This field is automatically filled from the email confirmation above.
Does your phone number match the number to which the screening link was sent?
Select...
Yes
No
What is the phone number to which the Screening Link was sent?
Issue Description
Date / Time of Issue *
Outcome attributed to Adverse Event (If Applicable):
Select...
Hospitalization
Life-Threatening
Other Serious or Important Medical Event
Required Intervention to Prevent Permanent Impairment / Damage
Disability or Permanent Damage
Death
None of the Above
Issue Description
Description of Issue: *
Additional information (Health Issues, Allergies, Medications)
Comments
Follow up
Would you like a member of our staff to contact you?
Optional: We can follow up if you need additional assistance
How would you prefer to be contacted for follow-up? *
Select...
Email
SMS/WhatsApp
Voice Call
No Contact Preferred
Submit Feedback
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