Western Health Feedback Form

Use our feedback form to let us know what you think. You can make a suggestion to improve care, share a compliment about our staff and services, or make a complaint.

For more information, please review our Feedback Process

If your Feedback is about a current inpatient, in the first instance please speak directly to the Manager or the Nurse/Midwife Unit Manager of the ward/area for timely action/response, if you have already done this and your concerns have not been resolved please continue to fill in this feedback form.

As your health and wellbeing is important to us, please do not use this form to ask medical questions. Contact your local doctor or present to your nearest Emergency Department. In an emergency, call 000.

Are you submitting this on behalf of someone else?

Yes

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Are you:

* must provide value

Your name

Your Phone Number

Your Email Address

Date of Birth

D-M-Y

Hospital number (if known)

Do you or the patient/consumer identify as Aboriginal and/or Torres Strait Islander?

Patient's name

Patient's Date of Birth (if known)

D-M-Y

Patient's hospital number (if known)

Patient's Phone number (if known)

Patient's Email Address (if known)

Your feedback is a:

* must provide value

Compliment - I am happy

Complaint - I am NOT happy

Enquiry

Suggestion

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Which hospital is your feedback about:

* must provide value

What part/s of Western Health is your feedback about?
(ie specific ward, medical unit, or service)

Please provide details of your feedback:

* must provide value

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What would have made a difference in this situation:

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Please tell us about the outcome you'd like:

* must provide value

Other

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Would you like a response to your feedback?

Yes

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Status

* must provide value

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.