Patient Forms - Admission Forms - Fertility Control Clinic

Client Feedback Form

It is important to give our patients a voice to share their experiences and for us to listen carefully to what is being said. We would like to know if we were respectful of, responsive to, the preferences, needs and values of our patients. Your experience will tell us what worked well and what might need to change.

Let us talk
You can start a conversation about any concerns,feedback or compliments you have by speaking with the staff member looking after you. Alternatively, you can speak to our Complaints Officer; use this form or email us your feedback.

What you should expect from us
Our policy is to promptly respond to patient feedback within 7 days of receiving information. We will share your feedback with our staff in a private and confidential manner to ensure we learn from the experience.

We will also work with you to assess the most appropriate way to resolve the complaint and provide the best outcome possible.

If you are not satisfied with the way we have responded to your feedback or wish to take further action, the Health Services Commissioner of Victoria provides independent mediation for complaints about health care services.

Patient Admission Form

PERSONAL DETAILS

DETAILS OF PERSON COLLECTING FROM FCC

EMERGENCY CONTACT PERSON

HEALTH INFORMATION

If patient has a temperature of ≥ 37.5℃; or answered YES to any of the questions below, undertake further risk assessment.

In the last 14 days, have you had any of the following?

Do you have or have you had any of the following medical problems?

Have you been diagnosed or are you at risk of having:

Client Feedback Form