Feedback Form

Here at Hospice we value your feedback, and would appreciate your comments as we continually strive to provide the best possible service.

Your Name (optional)

First name

Last name

Please tell us what services you have used *

How would you rate your experience *

What was of the most value to you?

How might we improve our service

Overall, how would you describe your experience with Hospice South Canterbury

What was your perception of Hospice South Canterbury before using our service?

Any other comments

If "Yes" Please provide name and contact number:

Do you agree to your comments being used and attributed to you in promotional material or grant applications by Hospice South Canterbury? *

Would you like to receive our newsletter? If yes please provide name and address

Postal address

Address line 1

Address line 2

Address line 3

Address line 4

Town/Suburb

City

Postcode/Zip

Or would you like to receive email newsletters (in the future)?

Email address

Contact phone number (cell pregerable)

Thank you for helping us to provide the best possible service for our community.