Complaints form

Use this form to file a complaint, a signal of dissatisfaction or a report. You can also do this anonymously.

Your complaint or report

Tell us what you would like us to know. Fields marked as optional can be left blank.

What is your complaint about? Tick whatever applies.

Is your complaint also about something that was, or could have been, unsafe?

YesNoI don't know

Patient complaint being handled (optional)

Date of report

Name

Location

Name of the patient

Date of birth of the patient

Treating doctor (optional)

What happened?

When did this happen?

Who was there? (optional)

What did this mean for you?

What would you like to happen?

Attachments (optional)

You may send along extra information, for example a letter, an email, a photo or another document.

You can upload up to 5 files of at most 10.0 MB each.

ConsentI give ECC permission to investigate my complaint. ECC may request information within the clinic for this purpose, but only where this is needed to handle my complaint.