Compliment, Suggestion or Complaint Form
Compliment, Suggestion or Complaint Form

 

We want to hear from you!

 

We welcome comments from patients, families, visitors, other service providers and members of the public. You may complete this form and submit by clicking the button at the bottom of the page. If you prefer to print and email or mail this form, please click here.


Please fill out the areas below:

Date: 

 

Are you a: (check the one that best applies)

Patient  Family Member/Friend/Caregiver  Substitute Decision Maker  External Health Professional/Agency  Other

 

What type of feedback would you like to provide:

Compliment  Suggestion Complaint

 

Have you spoken to staff about your feedback?

Yes  No

 

How are we doing? Please describe your feedback:

 

What would you like to see happen as a result of giving your feedback?

 

If you would like someone to respond to you, please fill out the following:

Your name: 

 

Patient care unit or program if applicable: 

 

Phone #:   Can a message be left at this number? Yes  No

 

If this form was completed by a staff member on behalf of a patient:

Name of staff member: 

 

Unit/Program:   Ext.:



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