Feedback Form

Please tick the relevant box/s:

Compliment
Suggestion
Complaint

Please complete patient details if relevant:

Patient's name

Patient's NHI or date of birth

Patient's email address

Patient's postal address

Patient's telephone number

If this is a complaint, please note that privacy legislation requires that a complaint made on behalf of someone over the age of 16, and who doesn't have a Power of Attorney, MUST have consent from that person.

The patient will be phoned to obtain verbal consent.

Details

Date of occurrence

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

Location:
Base Hospital (New Plymouth)
Hāwera Hospital
Health Centre Please select Waitara Opunake Patea Stratford Mokau
Other (please specify):   

Your feedback

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Patient
Relative
Visitor
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If you are not the patient please fill in the following details:

Your name

Your NHI or date of birth

Your email address

Your postal address

Your telephone number

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

Email
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