PATIENT FEEDBACK FORM
Date:
Type of Feedback:
Compliment
Complaint
Name:
Address:
Home Phone:
Mobile Phone:
Email Address:
Relationship to Patient
Self
Spouse
Parent
Other:
Nature of your comment: Please check the boxes below which best describe the nature of your comment; provide details below.
Complaint: Date Incident occurred:
Substandard Care (eg, misdiagnosis; negligent care etc)
Unprofessional Conduct (eg breach of privacy etc)
Office Practice (eg inattentive; rude or abusive behaviour etc)
Substandard Facilities or Equipment (eg cleanliness concerns; cluttered etc)
Scheduling or Appointment Issues (eg difficulty scheduling etc)
Prescribing Issues (eg medication errors)
Other:
Comments: (please be as clear and concise as possible:
Compliment:
Quality of Medical Care
Outstanding Customer Service
Staff Assistance/Support
Caring and Compassionate
Friendly and courteous
Other
Comments: Please be as clear and concise as possible
Regarding this comment I wish to be contacted:
Yes
No
Our Practice Manager will respond to your feedback.
Signature:
Filing a compliment or complaint is strictly voluntary. Information submitted on this form is treated confidentially.