RURAL HEALTH SERVICES

Feedback

Your thoughts about our services are important to us, and they will help us to improve the standard of your care.

If you would like to make a comment about any service or care you or your family have received, please complete the form below.

All comments are treated in a confidential and sensitive manner and will not jeopardise any future care to you and your family.

Please ensure all fields marked with '*' are completed.

Your Full Name: *
Your Street Address:
Your Phone No:
(including country code)
Your Email Address: *
Patient Name: *
Patient Address: *
Please check this box if you are making the complaint on behalf of someone else:

Date(s) of complaint event:
Person(s) involved:
(if known)
Where did the event take place?: *
Ward/Department Unit:
Please state your concern: *