Patient complaint and compliment form

You can submit your feedback using this online form. Read about other options and the complaints process on the patient complaints and compliments page, or contact the complaints coordinator on (08) 8999 2572 or dohconsumerfeedback@nt.gov.au

If your complaint relates to a breach of information or privacy, please use our Privacy Complaint Online Form instead.

Required fields are marked with an asterisk (*).

Type of feedbackComplaintComplimentEnquirySuggestion

Who is providing the feedbackPatientFamily memberCarerOther

If you are providing feedback on someone else’s behalf, have you received consent to do so?YesNoNA

Please note we are required to confirm consent directly with the patient and contact will be made once the feedback is received.

Submitter details

MrMrsMsOther

First name

Last name

Phone number

Email address

Date of birth (if you are the patient)

Patient details

If you are providing the feedback on behalf of someone else, provide the patient’s details below:

MrMrsMs

Patient - First name

Patient - Last name

Patient - Phone number

Patient - Email address

Patient - Date of birth (so we can look at your file)

Feedback information

Please select the service you are providing feedback about.

The region where you accessed the service:

• Top End
• Central Australia

In case of a hospital service:Please selectAlice Springs HospitalGove District HospitalKatherine HospitalPalmerston Regional HospitalRoyal Darwin HospitalTennant Creek Hospital

In case of non-hospital services:Please selectAged careAlcohol and other drugsCancer screeningChildren's developmentClinic 34COVID-19 testingCommunity health clinicEnvironmental healthHearingImmunsationMental healthOral healthPrison health and police watch houseTerritory Equipment Program and Seating Equipment and Technical Service (TEP and SEAT)Tuberculosis or leprosy clinicOther

What date (approximately) did you access the service?

Provide a brief summary of your feedback (up to 250 words) *