Submit a complaint

Step 1 of 6 (About You)


This form is designed to help you make a complaint to the Health and Disability Commissioner about the provision of health or disability services to you or someone else. Before filling in the form, you may like to consider the alternative of seeking the assistance of a Health and Disability Consumer Advocate to resolve your complaint at the local level (tel 0800 555 050 or email advocacy@hdc.org.nz). If you have not already done so, you may also wish to consider taking your complaint directly to the provider. If you proceed with the form, please check that you have answered all the questions marked with an asterisk, as we need this information to help us review your complaint.
Part A - About You *Your details (The complainant)

Name:	*

Address:	*

Home Phone:	* Business:

Fax:

Email:

Fill out this section only if you are complaining on behalf of someone else, ie, the person who received the health or disability service. Please supply the person's details below:
Name:

Address:

Home Phone:	Business:

Fax:

Email:

	What is your relationship to that person?
Relationship:

	Is that person aware you are complaint on his or her behalf?
Aware:	Yes No

	If no, is there a particular reason the person is not aware of the complaint?
Reason:

	Are there any other complainants involved in this complaint, ie, advocate, friend, lawyer? Please list details below:
Other Contacts: