Customer Services Feedback Form

How are we doing? We rely on feedback from you to let us know how we are doing and to help us improve. Please tell us:

  • When things are better than expected
  • Any suggestions for improvement
  • When you are not satisfied
Please fill out all the fields below:

Your name (person filling out this form)

Email address

Postal address

Telephone number

If this is a complaint, we advise that national privacy legislation requires us to release personal health information only to people who are entitled to that information. In the main, these are:
a) parent(s) of children under the age of 16 years, or
b) persons for whom the complainant holds an activated Power of Attorney.

If neither condition applies, the patient must confirm awareness of and support for the complaint by completing the line below.

Name of patient (if not the complainant)

Date of occurence

Service/department: (eg Maternity, Outpatients, Emergency etc)

Health Centre

Your statement

Are you a (tick a box):
Other (please specify):   

I prefer to be contacted regarding this matter by (please tick one)

Last updated: Wednesday, August 2, 2017

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