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Please tick if you require an interpreter.

If an interpreter is required, please advise on language needed:

Please tick if you require an Aboriginal and Torres Strait Islander Hospital Liaison Officer.
I would like to compliment staff / Department.
I would like to make a suggestion/share a concern

Are you the patient?

If No, what is your relationship to patient?

If your relationship to patient is 'Other', please specify:

Does the patient know you are contacting us on their behalf?

Patient's Name

Patient's Date of Birth:

Today's Date:

Your Name:

Patient's Address:

Patient's Address

Telephone (bus. hours):

Email:

Facility/Person or Department you are commenting on:

Northern Health location:

Comments:

What would you like to see happen as a result of your comments?

If 'Other', please specify:

On a scale of 1-10, How likely is it that you would recommend Northern Health to a friend or family member? (10 Extremely likely, 0 Not likely at all).

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