Customer Services Feedback Form

How are we doing? We rely on feedback from you to let us know how we are doing and to help us improve.

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)



Last updated: Tuesday, August 4, 2020

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