1.

If you wish to make a comment, compliment or complaint, then please fill in this form.

Name:
Address:
Telephone Number:
Email:
Date:
2.

For the purposes of investigation of my complaint, I grant permission to the HSE to access my personal patient confidential information. This may be necessary in some cases to fully investigate your complaint.

3.

Details

Name of service about which you want to make a comment, compliment or complaint
Name of location (Hospital, Health Centre, Administrative Office)
Date of experience giving rise to the comment, compliment or complaint
4.

Please give full details of your comment, compliment or the nature of your complaint in the space provided overleaf.

Your comment, compliment or complaint details

Comments
5.
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