Royal Children's Hospital
Consumer Feedback Form
Send to: Consumer Liaison Officer Clinical Quality & Safety Royal Children’s Hospital Flemington Rd Parkville, Victoria 3052 Email – Judith.smith@rch.org.au Fax – (03) 9345 5050
About You Surname _________________________________________First name_____________________________ Address: ____________________________________________________________________________ _______________________________State:_______________________Postcode:_________________ Contact Numbers: H ( )_________________W( Yes )_________________Mob._____________________ If Yes which language _______________________
Do you require an interpreter ?
No
About the Patient - Only complete this section if you are feeding back on behalf of someone else Name __________________________________________________Date of Birth: __________________ Hospital UR no.(if known) ________________ Patient registration: Public
Private
The Person / Department / Ward you are providing feedback about Person(s)____________________________________________________________________________ Department ______________________________ and/or Ward ________________________________ Your Feedback (If the space here is not adequate, please attach a letter outlining your feedback)
If your feedback is a concern, what outcome are you seeking? _______________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________
Signature: ______________________________
Date: ____________