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This form is designed to help you make a complaint to the Health and Disability Commissioner about the quality of health or disability services provided to you or someone else.
Before filling in the form, you may wish to consider first talking to the provider you are unhappy with. Alternatively, seek the assistance of an Advocate to help you resolve your complaint at a local level, instead of going to the Commissioner.
If you decide to use this form, please check that you have answered all the questions marked with an asterisk.
Fill out this section only if you are complaining on behalf of someone else, ie, the person who received the health or disability service.
What is your relationship to this person?
Is this person aware you are making a complaint on their behalf? Yes No
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