Feedback - Complaints/Compliments

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I am a:

• Clinician
• Patient
• Other

Your Name *

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Contact phone number *

Your Department/Organisation/Surgery

Patient NHI (if applicable)

Details. Please include as much information as possible, examples and dates/times are helpful in tracing specific incidents: *

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Was there a negative patient outcome as a result of this incident?

• Yes
• No (Near miss)

Would you like to receive feedback on the outcome of this?

• Yes
• No