Maicare Diagnostic & Medical Centre – Complaint Submission Form

We value your feedback. If you have experienced any dissatisfaction with our services, staff, or facility, please let us know. Your concerns help us improve our care and patient experience.

Personal Information

Full Name:
[Your Name]

Contact Number:
[Phone Number]

Email Address:
[Email Address]

Date of Incident:
[Select Date]

Time (if known):
[Select Time]

Location of Incident:

• Reception
• Treatment Room
• Laboratory
• Pharmacy
• Wards
• Consultation Room
• Ultrasound/Imaging
• Other: [Specify]

Complaint Details

Type of Complaint:

• Service-related
• Staff attitude or conduct
• Cleanliness or environment
• Delays in service
• Billing or payment issue
• Privacy/confidentiality
• Other: [Specify]

Details of the Complaint:
[Please describe what happened, including names of staff if known, and any relevant details.]

Have you reported this issue before?
Yes
No
If Yes, please provide details:
[Write here]

Preferred Method of Response

Phone Call
Email
No response needed

Consent

I confirm that the information provided is accurate and I consent to Lifecare Community Medical Centre investigating this matter. I understand my complaint will be treated confidentially.

Signature (Optional):

Date:

All information provided will be handled confidentially and in accordance with our patient rights and privacy policies.