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Online Complaints Form

Online Complaint Form

Your Details

Salutation: *required

Given Names: *required

Last Name: *required

Date of Birth:

Gender: *required

Postal Address: *required

State: *required

Postcode: *required

Contact Telephone: *required

Mobile:

Email:

Preferred contact method:

My preferred language for communication with the Council is:

Patient Details

I am lodging this complaint on behalf of: *required Myself Another Person

If lodging this complaint on behalf of another person, please tell us your relationship to this person: *required

Has this person agreed to you making this complaint on their behalf? *required Yes No Not Applicable

Is this person deceased? *required Yes No

Please provide the relevant contact details below for the person who received the service

Salutation: *required

Given Names: *required

Last Name: *required

Date of Birth:

Gender: *required

Postal Address: *required

State: *required

Postcode: *required

Contact Telephone: *required

Mobile:

Email:

Preferred contact method:

Complaint Details

Have you spoken with anyone from the Council prior to lodging this complaint? Yes No

If YES, please provide as much detail of the conversation as possible

Who is this complaint being made about? *required

Please provide the name of the podiatrist or student this complaint relates to:

Please provide the registration number of the podiatrist this complaint relates to (if known):

Where did the incident occur?

Please provide the name of the hospital or address of the practitioners rooms:

Please provide as much detail about the complaint as possible. What happened
(including when it happened, time, dates, actions and any specific details you believe are relevant), were there any other people present, what treatment was being received *required

The Council will provide specific details of the complaint to the health practitioner or student to seek a response from him/her

Have you approached the health practitioner or student about this complaint? *required Yes No

Have you spoken to anyone else about this complaint? *required Yes No

If YES, please provide details:

Is there any additional information you wish to provide? Yes No

If YES, please provide details:

Please be aware that the Council has a legal responsibility to deal with all complaints promptly. By submitting this form, you give consent to the Council to contact you and to make any inquiries the Council thinks appropriate to assess the complaint.

Under section 145A(1) of the Health Practitioner Regulation National Law (NSW) and the Health Care Complaints Act 1993, the Council and the Health Care Complaints Commission are required to consult with each other on the appropriate course of action for all complaints received.

Mandatory field(s) marked with *required

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