CUSTOMER FEEDBACK FORM
DateTime
TYPE OF FEEDBACK:
*
COMPLIMENT
COMPLAINT
NAME
First Name
Last Name
ADDRESS
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
RELATIONSHIP TO PATIENT:
*
SELF
SPOUSE
PARENT
DEPENDENT CHILD
LEGAL GUARDIAN
NATURE OF YOUR COMMENT:
(Please check the boxes below which best describes the nature of your comment.)
Date incident occurred:
*
-
Month
-
Day
Year
Date
COMPLAINT:
*
Delay in service, appointments, admission, transportation, response to questions, treatment.
Patient care: coordination of care, quality of care, department-to-department communication, etc.
Facility policy or procedures.
Cost/billing/insurance issues.
Lack of respect.
Lack of privacy.
Safety (Patient Environment): lighting, building security, patient supervision.
Environmental concerns: cleanliness, parking directional signage, plumbing, electrical malfunctions, etc.
Equipment issues: television, phones, call buttons, broken furniture, furniture is poor condition, etc.
Other
NARRATIVE COMMENTS (please be as clear and concise as possible; use extra pages if necessary)
*
Submit
Should be Empty: