P.O. Box 597045
Chicago, IL 60659-7045
All information will be kept confidential.
Nursing Home: _____________________________________________________ Address: __________________________________________________________ City: ________________________ State: ____________ Zip: ___________ Patient's Name: ___________________________________________________ Would you recommend this nursing home? Yes ____ No _____ Would you like to see an in-service for the staff that would assist them in learning more about HD patients? Yes ____ No _____ Your Name: ________________________________________________________
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