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Patient Advice and Information
Patient Advice

Patient Advice - Feedback Form

 

Please use the form to register your feedback

to Queen’s Hospital, Burton on Trent, Staffordshire

Your Details

Your Name: 

Telephone Number: 

Email Address: 

Address: 

What is the best time of day to reach you by telephone?: 

Patient Details

The name of the patient

Hospital number (if known) or Date of Birth

Patient's Address

Your relationship to the patient


What would you like to tell us?

If you are complaining on behalf of someone else we will need their consent. We will send you a consent form and keep your complaint on file until this is returned to us.

Ward or Department

Date of visit or admission

Details: 

The outcome you are looking for: 

 

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