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Name and Shame Listing Response
NAME : :
xxx ( replace xxx with the
Persons name and delete this instruction.
PRACTICE NUMBER : xxx ( If a
Doctor replace xxx with your Practice number If Not Remove it )
PERSONS EMAIL ADDRESS
:
xxxx ( replace xxxx
with the Persons email address and delete this instruction.)
PERSONS PHONE NUMBER:
xxx ( replace xxx
with the Persons Phone Number and delete this instruction. )
PERSONS COMPANY:
xxx ( replace xxx with
the persons company and delete this instruction. )
SITE REF NUMBER :
xx ( replace xx with the site reference
number and delete this instruction )
RESPONSE TO COMPLAINT :
]
xxx } 10 lines ( replace xxx with your
Citation and delete this instruction.)
NAME :
xxx ( replace xxx
with your name and delete this instruction ) We
will send a email to the person informing them of your
response )
MUST WE ADVISE THE PERSON OF YOUR
RESPONSE? YES / NO ( delete which is not applicable )
YOUR PHONE
NUMBER :
xx ( replace xx
with your Phone Number which will not be published )
By completing this form and
emailing it to us you confirm that all the information is
correct, and
NameandShame.Biz will not
be held responsible for publishing false information.
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Please Down Load a PDF
format Credit Card Form and Fax it to 086 244 6148 |