Rights, Responsibilities and Expectations

Your first name*

Your last name*

Telephone number*

Email address*

Mailing address

Preferred method of contact*
EmailTelephoneMail

Who is initiating the feedback / concern for patient*
PatientFamily / Designated Support Person (DSP)GovernmentHealthcare and Medical StaffOffice of the Ombud (includes Seniors. Advocate and Youth Advocate)Indigenous Health / Tribal Center Health StaffOther

Patient/client first name*

Patient/client last name*

Patient date of birth*

Geographic Area*
Fredericton AreaMiramichi AreaMoncton AreaSaint John AreaUpper River Valley Area

Facility Type:*
HospitalHealth CentreVeterans Health ServiceOther

Name of Facility:*

Select the type of feedback you are sending:*
Compliment for staff, physicians, or volunteersSuggestion(s) to improve health servicesQuestion(s) and/or Concern about patient care

Feedback and/or Concern Description*

Feedback and/or Concern Expectations*
My feedback/concerns are shared with the appropriate department and I do not want further contact.Follow-up with me once the investigation is complete. Patient Consent will be required.Follow-up with only the above mentioned person once the investigation is complete. This may include the sharing of personal health information . Patient Consent will be required.Follow-up with me AND the above mentioned person once the investigation is complete. This may include the sharing of personal health information. Patient Consent will be required.

Please attach any relevant documents