Name* First Last Address Street Address City State Post Code Email* Date* DD slash MM slash YYYY Time of event : AM PM AM/PM Name of Service:*GPcareCONNECTcareSummit Health Centre ServicesOtherIf other, please indicate which service below: Who or what is the subject of the feedback?: Details of the feedback?*Terms and Conditions* I understand that by ticking this box I am stating that the information I have supplied provides a true and correct representation of the events that occurred and that prompted this feedback. I understand that the information I supply will be used by the organisation to further improve its service delivery and my feedback will be treated in accordance with relevant legislation. Processing Feedback We shall acknowledge all feedback within 7 working days. If the feedback relates to a service complaint, once reviewed, you will receive a written explanation of the outcome, and information regarding changes that will be made to policies, procedures or other internal processes where relevant. We shall have due regard to your privacy. If you are dissatisfied with the manner in which your feedback is dealt with, you can contact the Health and Community Services Complaints Commissioner phone: 1800 232 007 or on the website www.hcssc.sa.gov.au CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.