Please tick the relevant box/s:
Compliment
Suggestion
Complaint

Your name (person filling out this form)

Email address

Postal address

Telephone number

If this is a complaint, please note that privacy legislation requires that a complaint made on behalf of someone over the age of 16, and who doesn't have a Power of Attorney, MUST have consent from that person.

This can be done by having the patient complete the declaration in the next line.

I am the patient in the situation complained of, and this complaint is made with my full support and knowledge.

Patient name

Date of occurrence

Service/department: (eg Maternity, Outpatients, Emergency Department etc)

Hospital:
Base
Hawera
Health Centre

Your statement

Are you a (tick a box):
Patient
Relative
Visitor
Other (please specify):   

I prefer to be contacted regarding this matter by (please tick one)

Email
Letter