Health PEI Compliments and Complaints

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Identification

What type of feedback are you providing? *

First Name *

Last Name *

Do you wish us to contact you? *

Your Email Address *

You will receive a confirmation of this submission to the email you provide here.

If you indicated that you wish us to contact you, we will use this email address.

Please make sure it is entered correctly.

Phone Number

Compliments and Complaints

Date event occurred *

Year

Month

Day

Facility/site where event occurred *

Example: QEH, Colville Manor, Harbourside Health Centre, etc.

Location of event *

Example: Unit 1, Emergency Department, Diagnostic Imaging, Medical Clinic, etc.

What is the nature of your compliment or complaint? *

Other, please specify *

Describe the event. *

What happened and the order in which things happened. Where possible, include dates and list any phone calls, letters or meetings that took place.

Describe what action you would like taken.

Acceptance

Personal information on this form is collected under the authority of Section 31(c) of the Freedom of Information and Protection of Privacy Act and will be used for the purposes of resolving or responding to your compliment or complaint. Questions on the collection and use of this information can be directed to Health PEI at (902) 368-5272.

I agree to the disclaimers and privacy statements.

Disclaimer Agreement *