Health Unit Client Feedback Form

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Name

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email(Required)

Date

Time

Would you like to be contacted regarding your feedback?

Yes

If so, what is the best way to contact you?(Required)

What Health Unit program is your feedback about?(Required)

Please specify what your feedback is about.(Required)

Who have you dealt with in this organization with respect to your feedback?

Please summarize the matter you are providing feedback about and include any relevant dates and details.

If applicable, summarize what steps you have taken to try and resolve the issue thus far and what response you have received.

Please Note

It is important in addressing the issues involved with any complaint that the complaint be made at the time of service or very soon after. All complaints must be made within 30 calendar days of the service being provided, or if the complainant is not aware of this time line, within 30 calendar days of receiving notice of the complaint procedure. This ensures that the individuals involved in your complaint are available to address your concerns.

Most concerns are dealt with as soon as possible, but some require examinations that could take up to 30 days from the time you submit your feedback. If this timeline cannot be met, you will be contacted and given a reason why this is being adjusted.

If resolution is required prior to the 30 day timeframe, please explain why.

Please Note

The personal information collected on this form will be used only for the purposes of responding to your feedback and will be kept confidential.

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