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Health Complaints Commissioner Tasmania
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Phone 1800 001 170
Health Complaints Commissioner Tasmania
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Contact us
Phone 1800 001 170
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Health Commission Complaint Form
1. Consumer of Service - Person who received the health service
Title
Mr
Ms
Mrs
Miss
Other
Other Title (Please specify)
Surname
First Name
Address
Suburb
State
TAS
ACT
NSW
NT
QLD
SA
VIC
WA
Post Code
Date of Birth (dd/mm/yyyy)
1
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31
Jan
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Dec
1900
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2015
2016
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2018
2019
2020
2021
2022
2023
2024
Telephone (9:00am to 5:00pm)
Mobile
Fax
Email Address
What is your preferred method of contact?
Postal
Telephone
Mobile
Email
Fax
Do you have a disability or other special needs?
Yes
No
(please specify)
Are you of Aboriginal or Torres Strait Islander origin?
No
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, both Aboriginal and Torres Strait Islander
Are you from a non-English speaking background?
Yes
No
(please specify)
Will you require an interpreter?
Yes
No
