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Prescribers Details  
Name:  
Phone:

Veterans Details
Name:
DVA File Number:

Please select the most appropriate statement for the following:
Did the equipment meet your expectations?  
If not, please provide details:
   
Was delivery within allow 48 hour period?
Were The Country Care Group staff friendly and helpful?
If not, please provide details:
Overall, how would you rate our services?
Please provide any further comments and/or suggestions below: