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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