Complaint Form printable pdf download

Tahunanui Medical Centre - Complaint Form

Tahunanui Medical Centre takes complaints seriously and every complaint is seen as an opportunity to

look at how we do things and improve our services. Our aim is to achieve a mutually satisfactory conclusion

and, where appropriate, take action to ensure the situation does not arise again.

Date ________________

Details of the Person Making the Complaint

Name:

_____________________________________________

Address: __________________________________

Contact Telephone Numbers:

__________________________________

Home: ______________________

__________________________________

Work: ______________________

__________________________________

Mobile: ______________________

What happened?

1. What happened?

Describe the event that you want us to know about, please give all the details that you can remember

_____________________________________________________________________________________

2. When and where did it happen?

Please state the date, time and location of the incident

_____________________________________________________________________________________

3. Did anyone witness what happened?

Please give names and contact details if possible

_____________________________________________________________________________________

Tahunanui Medical Centre – Complaint Form September 2012

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Complaint Form