Enquiries and Feedback Form

Send us an enquiry or feedback

When you see a * it means that it must be completed. Other fields are optional.

Are you filing this complaint on behalf of someone else?*
- Yes
- No
Who are you complaining on behalf of?*
Please indicate the patient's relationship with you.
- Family
- Friend
Have you been given permission to make the complaint on their behalf?*
- Yes
- No

What is YOUR full name?*
(Representative of Patient or Health Consumer)
What name do you prefer to be called by...
Please provide AT LEAST one way we can contact you (i.e. email, phone or address.)
Email
Enter Email Confirm Email
Phone
Address
Street Address Address Line 2 City ZIP / Postal Code Country
You haven't provided any contact details yet!*
Are you sure that you don't want to leave contact details with us.
- Yes, I'm sure.

Type of question or enquiry*
Hospital, Facility or Service*
Enquiry details*
Please be specific.
Complaint details*
Please be specific.
Complaint details*
Please be specific.
Compliment details*
Note: We will never publish any identifiable information without first receiving your permission.
Your suggestion*
Suggested resolution
(Optional) What could we do to make things better?

Place of event*
If not about an event, please pick a place related to this feedback, or your location.
Date of event(s)
Name of Facility or Ward*
The event took/takes place in which facility or ward? If not related to an event, type: NA

Your Full Name*
Patient's or Health Consumer's Full Name*
Your Name*
Your Name
(Optional)
NHI Number (optional - Please provide, if known)
The NHI number (first three are letters and the last four are numbers) helps Health Providers identify who you are.
Date of Birth
Date of Birth
Please provide AT LEAST one way we can contact you (i.e. email, phone or address).
Please provide AT LEAST one way we can contact the person you are representing with this complaint (i.e. email, phone or address).
Email
Enter Email Confirm Email
Phone
Address
Street Address Address Line 2 City ZIP / Postal Code Country
You haven't provided any contact details yet!*
Are you sure that you don't want to leave contact details with us.
- Yes, I'm sure.
Comments
This field is for validation purposes and should be left unchanged.

Page last updated: 17 January 2019

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