Customer Feedback Form

CUSTOMER FEEDBACK FORM

Dear Patient,

Thank you for your feedback.

The Southern Fleurieu Family Practice welcomes customer feedback whether in the form of a

complaint, compliment or comment. We will use this feedback as part of our internal process to

improve or consolidate the services provided by this practice.

Where appropriate and requested the Practice will respond to your feedback after appropriate

investigation. Every effort will be made to respond within 10 working days.

Surname

First Names

Address

Telephone

Feedback Type

(select one)

□

Compliment

Complaint

Comment

)

(please use overpage if more space is required

□

Response Requested

No Thanks

Yes Please

Signed

Date _ _ / _ _ / 2011

………………………………………………………..

Z:FormsCustomer Feedback Form 201104.doc

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Parent category: Business