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FEED BACK FORM

Our Commitment

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At OPlus Health we value feedback and are committed to providing safe, respectful and high-quality healthcare services.

Patients, carers, family members and visitors are encouraged to provide compliments, suggestions, concerns or complaints. Feedback helps us improve our services.

You may lodge feedback anonymously; however, providing contact details allows us to investigate and respond.

PERSON PROVIDING FEEDBACK

Person providing feedback
Birthday
Day
Month
Year
Preferred contact method

DETAILS OF THE CONCERN / COMPLAINT

Date and time of Incident
Day
Month
Year
Time
HoursMinutes
Location

WHAT OUTCOME ARE YOU SEEKING?

What outcome are you seeking?

SUPPORTING INFORMATION

Have you previously discussed this concern with practice staff?
Yes
No
If yes, with who and when?
Documents attached
Yes
No
If yes, list below

PRIVACY CONSENT

I understand that:

• Information provided will be handled in accordance with applicable Australian Privacy requirements.

• My complaint will be reviewed confidentially where possible.

• Information may be shared only with staff involved in investigating or responding.

• Lodging a complaint will not affect access to healthcare services.

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Date
Day
Month
Year
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