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Guide to Complaint Handling in Health Care Services

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<strong>Compla<strong>in</strong>t</strong>/Feedback Form<br />

Feedback, suggestions or compla<strong>in</strong>ts about our health service are appreciated<br />

and are taken seriously.<br />

Date:<br />

Consumer<br />

Name (Ms/Mrs/Mr):<br />

Address:<br />

Telephone: home work mobile<br />

Name of patient<br />

If you are not the patient, what is your relationship <strong>to</strong> the patient?<br />

Is an <strong>in</strong>terpreter needed? No Yes – preferred language?<br />

Details<br />

Hospital Department<br />

Date of <strong>in</strong>cident/s<br />

Approximate time of <strong>in</strong>cident/s<br />

Name of relevant staff member (if known)<br />

What happened?<br />

What outcome would you like?<br />

Upon completion, please give this form <strong>to</strong> a staff member.<br />

40 Sett<strong>in</strong>g up your system/<strong>to</strong>ols

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