Compliments, Suggestions and Complaints
    If you would like to make comment regarding your visit to our facility please complete this ‘Have Your Say’ Feedback Form.

    ComplimentComplaint

    Details of who is completing this form

    Email:

    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
    YesNo

    Date compliment/complaint happened:

    Name of Hospital/Community and Allied Health Unit/Outpatients Clinic:

    Department:

    Do you or the patient require an Interpreter?
    YesNo

    If yes, which language

    Details of patient accessing South West Hospital and Health Service

    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
    YesNo

    Feedback Provider’s contact details

    MrMrsMsMissDr

    First Name:

    Last Name:

    Address:

    Suburb:

    Post Code:

    State:

    Home Phone:

    Mobile:

    Work Phone:

    Feedback Information:

    Your expectations.
    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

    Other

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