Client Relations Feedback Form Your story may be about you or someone you care about. If you are telling us about someone else’s experience, they may need to give us permission to look into their care. To avoid security issues, please do not use “special characters” in form fields (eg. !, @, ‘, #, $, %, ^, &, *, (, ), ?, etc.). Person AffectedName First Last Telephone NumberEmail Please leave us your name and a phone number where we can call you during the day. We may need to speak with you to get more information. As well, we’ll want to tell you what we have learned. Your informationName First Last Telephone NumberEmail What is your relation to the patient? Self General family Friend Visitor Feedback Details We need to know when things have gone well and when things could have gone better. Telling us about your experience can help us improve your care and the care of others. The privacy of the patient, resident or client will be protected at all times under the Personal Health Information Act. Tell us your storyWhen did this happen?