Customer Feedback Form

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Appendix 12: Template – Feedback form
We welcome your feedback.
Our service is committed to providing high quality imaging services and care. We value your
feedback – including complaints.
Please let us know what we do well and where we can improve our services.
This is a
compliment
complaint
comment
Date received
: _________
Feedback
Follow up (optional)
Please provide your details if you would like us to contact you about your feedback.
Name: ______________________________________________________________________________
Phone / email: ________________________________________________________________________
Thank you for taking the time to provide feedback about our service.
OFFICE USE ONLY
Date entered in Quality Improvement Register:
By (Name):
Follow-up by:
Response provided: Y / N
Action taken is to be recorded on the reverse of this form.
DIAGNOSTIC IMAGING ACCREDITATION SCHEME USER GUIDE – Appendix 12

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