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, 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.

This can be done by having the patient complete the declaration in the next line.

I am the patient in the situation complained of, and this complaint is made with my full support and knowledge.

Patient name

Date of occurrence

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: Friday, Nov 22, 2019

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