1Introduction2Representative details3Clients details4Your complaint5Your expectations6Privacy agreementWe will use the information on this form to start an investigation into your complaint. This form will be discussed with the manager of the clinic and service, as well as the treating clinician (if required).You will receive acknowledgement of your complaint within 5 working days of receipt.Read our privacy statement to see how we collect, store, and manage information.Are you making this complaint on behalf of yourself or someone else?We will contact the affected client directly, and we will only engage with their representative once we have obtained the client’s authorization due to the sensitive nature of the matter. Myself Someone elseRepresentative detailsRepresentative Title(Required)Please selectMrMsMrsMissMxDrEst ofRepresentative Pronouns(Required)Please selectHe/HimShe/HerThey/ThemPrefer to self-describeSelf described pronouns(Required)Representative Name(Required) First Last Representative Email(Required) Representative Phone(Required)Your communication needs or preferencesClients detailsTitle(Required)Please selectMrMsMrsMissMxDrEst ofPronouns(Required)Please selectHe/HimShe/HerThey/ThemPrefer to self-describeSelf described pronouns(Required)Clients Name First Last Clients Email(Required) Clients Phone(Required)Your complaint3. Which clinic or service is your complaint aboutRegion(Required)Please selectNorthlandAucklandWaikatoBay of PlentyHawkes BayTaranakiManawatu/WhanganuiWairarapaWellingtonMarlboroughTasmanCanterburyWest CoastOtagoSouthlandIs you complaint about Clinic ServicePlease state the clinic your complaint is about?Please state the service your complaint is about?Tell us about your complaint(Required)Your expectationsWhat would you like to happen?Privacy agreementWe need your permission to discuss your complaint with the clinic or service so we can help resolve it.Please confirm we (TBI Health Group Ltd) can:Share the information you provide with the relevant clinic or service manager.Receive information from the clinic or service manager which is relevant to your complaint. Read our privacy statement to see how we collect, store, and manage information.Privacy agreement I agree I do not agreeThis means we will be unable to discuss your complaint with the clinic or service. This may limit our ability to assist you.
