Feedback Form
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Your First Name
Your Last Name
Your Email Address
Your Phone Number (enter with no spaces)
Your Address
Are you providing feedback on behalf of someone else?
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No
Yes
Relationship to Customer
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Relative
Friend
Advocate
Staff Member
Other
Customer First Name
Customer Last Name
Customer Address
</textarea>
Bethanie Service
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Aged Care Home (Nursing Home)
Community Care - In Home
Community Care - Living Well Centre
Retirement Villages
Bethanie Housing
Village Sales
Other
Bethanie Location
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House/Wing or Centre
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Type of Feedback
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Compliment
Suggestion
Complaint
Customer Survey
When did this happen?
Tick if you felt unsafe (If you currently feel unsafe and it is an emergency dial 000 immediately)
What feedback would you like to share?
What outcome would you like as a result of this feedback
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