Complaint / Feedback FormFeedback, suggestions or complaints about our service are appreciated and are taken seriously. You are welcome to use this form, email, phone or SMS to make a complaint or provide your feedback. You are also welcome to remain anonymous in providing your complaint/feedback.

Date: ___________________

Name: ________________________________________________________________________________

Address:_______________________________________________________________________________

Telephone: Business hours: ______________________ After business hours: ______________________

Name of client / participant (this is not required to be completed):_____________________________

If you are not a client of WHR Allied Health, what is your relationship to the client?

______________________________________________________________________________________

Details of Feedback, Suggestion or Complaint: Include as much detail as you can, including the date and time of any incident, where it happened, what happened, who was involved (if you are sharing this information), any witnesses and what outcome you would like. Please feel free to attach additional pages if you need to. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Name of relevant staff member (if known): ______________________________________________________________________________________

Upon completion, please give this form to a WHR Allied Health staff member or email through to Admin@whralliedhealth.com