Details of who is completing this form
Your First Name:
Your Last Name:
Or would you like to remain anonymous?
If you remain anonymous we cannot contact you to discuss but the matter will be reviewed as appropriate
Date compliment/complaint happened:
Name of Hospital/Community and Allied Health Unit/Outpatients Clinic:
Do you or the patient require an Interpreter?
If yes, which language
Details of patient accessing South West Hospital and Health Service
Feedback Provider’s contact details
What actions do you want to happen from this process?
Register complimentRegister concernReceive explanationObtain apologyObtain refundAccess serviceChange procedureChange policyCompensationStaff performance mgmtChange physical environmentProvide staff training Resource availability