Contact Form

Are you filing this complaint on behalf of someone else?*
- Yes
- No
Who are you complaining on behalf of?*
Please indicate the patient's relationship with you.
- Family
- Friend
Have you been given permission to make the complaint on their behalf?*
- Yes
- No

What is YOUR full name?*
(Representative of Patient or Health Consumer)
What name do you prefer to be called by...
Please provide AT LEAST one way of how we can contact you (i.e. email, phone or address.
Email
Enter Email Confirm Email
Phone
Address
Street Address Address Line 2 City ZIP / Postal Code Country
You haven't provided any contact details yet!*
Are you sure that you don't want to leave contact details with us?
- Yes, I'm sure

Enquiry details*
Please be specific.
Complaint details*
Please be specific.
Complaint details*
Please be specific.
Compliment details*
Note: We will never publish any identifiable information without first receiving your permission.
Your suggestion*
Suggested resolution
(Optional) What could we do to make things better?

Place of event*
If not about an event, please pick a place related to this feedback, or your location.
Date of event(s)
Name of Facility or Ward*
The event took/takes place in which facility or ward? If not related to an event, type: NA

Your Full Name*
Patient's or Health Consumer's Full Name*
Your Name*
Your Name
(Optional)
NHI Number (optional - Please provide, if known)
The NHI number (first three are letters and the last four are numbers) helps Health Providers identify who you are.
Date of Birth
If this complaint is about what happened to a patient, providing the date of birth here will ensure that we are looking at the records of the right person, in case there are more patients with the same name that have been through our health system.
Please provide AT LEAST one way of how we can contact you (i.e. email, phone or address).
Please provide AT LEAST one way of how we can contact the person you are representing with this complaint (i.e. email, phone or address).
Email
Enter Email Confirm Email
Phone
Address
Street Address Address Line 2 City ZIP / Postal Code Country
You haven't provided any contact details yet!*
Are you sure that you don't want to leave contact details with us?
- Yes, I'm sure
Please click: 'Send' to submit your complaint. Once the form has been submitted a member of our team will be in contact with you soon to acknowledge and then respond to the issues you have raised.
Please click: 'Send' to submit your enquiry.
Please click: 'Send' to submit your compliment.
Please click: 'Send' to submit your suggestion.
Phone
This field is for validation purposes and should be left unchanged.

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