Making a complaint about a health or disability …
Making a complaint about a health or disability service
Most providers find that feedback (positive and negative) helps them identify what will improve the quality of their service
Name of consumer…………………………………………………………………..
Name of the person making the complaint…………………………………………
(if not the consumer)
Relationship to the consumer………………………………………………………
Contact address………………………………………………………………………
…………………………………………………………………………………….......
Phone (home) ………………(work)………………(mobile)……………………………
Fax……………………………………..email…………………………………………
Name of provider/person you want to complain about …………………………...
………………………………………………………………………………………...
Name of the service………………………………………………………………….
Describe what happened (attach extra pages if needed)
Desired outcome (what you want to happen as a result of this complaint)
Date this happened…………………………Signature……………………………..
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