Patient Feedback form

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.