Qhia peb txog qhov koj tuaj ntsib peb no zoo li cas. Peb xav paub.

Qhov koj tuaj no puas mus raws siab xav? Thov qhia peb. Peb nav thwm koj cov lus teb. Peb yuav siv koj cov lus teb no mus hloov kom yav tom ntej no koj tuaj hauv Healthpartners yuav zoo tshaj zaum no

Yog koj cov lus teb no muaj feem mus rau kev nyab xeeb los sis tu/kuaj koj tsis zoo, thov hu rau lub hoo maum me (clinic) sai

_{*Thov teb txhua lo lus nug (muaj tej lo peb cia nej xaiv seb teb los tsis teb). Tsis lo koj npe rau cov lus teb}

Clinic Feedback form (Hmong Language) - User Comments:

(Reason for visit)

(Clinic Location)

Kev tiv tauj koj

(Address 1)

(Address 2)

(City)

(State)

(Zip code)

(Email address)

(Phone number)

(Phone extension (if applicable))

(Patient Name (if different than above))

(Patient date of birth)

(Preferred contact method: Xov tooj=phone number email=email)

(Would you like us to contact you about this? Xav=yes Tsis Xav=no)