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Give Feedback on a Healthcare Provider
Did you have a great experience with a healthcare provider you found through Garden State Equality's
Affirming Healthcare Map
? Did you have a difficult experience? Let us know using this feedback form.
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Name of healthcare facility
If your healthcare provider is an individual practitioner, you can leave this field blank.
Your answer
Name of healthcare provider
Your answer
How would you rate your experience on a scale of 1 to 5?
Poor
1
2
3
4
5
Excellent
Clear selection
Why did you give this rating?
Your answer
Is there anything else you'd like to share about your experience with this healthcare provider?
Your answer
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