Customer Feedback Form printable pdf download

Customer Feedback Form

Appendix 12: Template – Feedback form

We welcome your feedback.

Our service is committed to providing high quality imaging services and care. We value your

feedback – including complaints.

Please let us know what we do well and where we can improve our services.

□

This is a

compliment

complaint

comment

Date received

: _________

Feedback

Follow up (optional)

Please provide your details if you would like us to contact you about your feedback.

Name: ______________________________________________________________________________

Phone / email: ________________________________________________________________________

Thank you for taking the time to provide feedback about our service.

OFFICE USE ONLY

Date entered in Quality Improvement Register:

By (Name):

Follow-up by:

Response provided: Y / N

Action taken is to be recorded on the reverse of this form.

DIAGNOSTIC IMAGING ACCREDITATION SCHEME USER GUIDE – Appendix 12

Customer Feedback Form