Feedback form

Your feedback is important to us. It helps us identify areas for improvement and acknowledge things we’ve done well.

You can give your feedback by filling in this online form or you can contact us by:

Your feedback for us

Tell us a bit about yourself, your experience with our service and your feedback using the form below.

The information you give us when you fill in the feedback form will be kept safe by the Patient Liaison Officer. It will be only be used to address your feedback if you haven’t submitted anonymously.

What kind of feedback do you have? *

Compliment
Complaint
Suggestion

Your feedback for us *

Date of event If your feedback is about what happened on a specific date.

Day Month Year

Which location, service or hospital is your feedback about *

Which unit, ward or area is your feedback about? *

What outcome would you like from your complaint feedback?

Concern acknowledged and formally registered
Receive an apology
Prevent reoccurrence
Improved access to service and resources
Please call me so I can give more information
I'd like to get an explanation
I'd like a second opinion

Do you wish to be contacted with a response? Compliments are sent to staff and sometimes displayed in public health service spaces. You will not get a response usually. Suggestions for improvement will be reviewed and discussed. You may not get a response.

Do you wish to remain anonymous? * We may not be able to fully review anonymous feedback, but it will be recorded and reviewed. We’ll send complaints to senior staff to assist with reviewing your concerns.

Yes, do not fill out the details below
No

Your name If you don't wish to remain anonymous

Your date of birth We will only use this to make sure we identify the correct person.

Day Month Year

Your address

Your phone number

Your email address

Do you consent for us to access your health records if required to review your concerns? Depending on the issue, selecting ‘No’ may limit our ability to fully review your concern.

Are you giving feedback on behalf of someone else? If you’re giving feedback on behalf of someone else we’ll need to contact them before we can review and release information to you. This may not apply if they’re a child under 16.

Your relationship to them Enter your relationship to them, like parent.

Their name If you're giving feedback on behalf of someone else.

Their date of birth We will only use this to make sure we identify the correct person.

Day Month Year

Their UR or patient number

Their address

Do you have their permission to provide feedback on their behalf?