Complaints/Kudos Patient Feedback Form First Name * Last Name * Classification – Choose * 1) Patient 2) Family member of patient 3) Friend of patient 4) other explain Classification – Choose Contact number * Location of incident (zone) * North Zone Edmonton Zone Central Zone Calgary Zone South Zone Download Zones Map Type of Feedback * 1) Compliment for staff 2) Suggestion for Improved Services 3) Concern about care received Feedback Description * HIA/FOIP statement Personal or health information collected will only be used for the purpose of tracking, follow up, communications and trending regarding your health experience concern. Information is collected pursuant to section 33 of the Freedom of Information and Protection of Privacy Act (FOIP) and under the authority of Section 20(b) of the Health Information Act (HIA) for the purpose of administering AHS' patient complaint and feedback program. reCAPTCHA If you are human, leave this field blank. Submit Δ
