Contact ALL EMERGENCIES – PH. 111 Kaikōura Healthcare25 Deal StreetKaikoura7300 Phone: 03 319 3501 admin@kaikourahc.co.nz Facebook This field is hidden when viewing the formNext Steps: Sync an Email Add-OnTo get the most out of your form, we suggest that you sync this form with an email add-on. To learn more about your email add-on options, visit the following page (https://www.gravityforms.com/the-8-best-email-plugins-for-wordpress-in-2020/). Important: Delete this tip before you publish the form.How can we help?Use this form for general questions, suggestions, complaints, or bouquets. Please note: This form is NOT for booking appointments. If you need to schedule a visit, please call us directly or use the MyIndici Patient Portal → Reason for ContactGeneral Question/CommentSuggestionComplaintBouquet (Positive Feedback)General Section Starts HereGeneral Questions & Comments Got a question or something you'd like to share? Use this form to get in touch with general enquiries or comments — we’re here to help.Bouquets Section Starts HereBouquets Had a great experience you'd like to share? We’d love to hear about it — your kind words help boost team morale and celebrate what’s working well.My Bouquet is For The way I was treated An interaction with staff A process Other OtherThe Date Was DD slash MM slash YYYY By selecting the date, it helps us recognize great service on a specific day.The DetailsPlease help us by providing as much detail as possible.The Staff or People Involved Add RemovePlease use one line for each name and click + if more than one.Suggestions Section Starts HereSuggestions Got an idea to help us improve? Use this form to share your thoughts — big or small — on how we can make our services even better. Complaints Section Starts HereComplaints Something not quite right? If you’ve experienced an issue or have concerns, please let us know. Your feedback helps us improve the care we provide.My ideas and suggestionsTell us your idea! We welcome suggestions to improve our services.Complaints Section Starts HereMy feedback is relating to:(Required) Staff Processes Other Date DD slash MM slash YYYY By selecting the date, it helps us specifically address the issue.The detailsPlease provide as much detail as possible to help us understand your concernAbout YouYour Name(Required) First Last How Can We Reach You?What is your preferred method of contact Preferred Method of ContactEmailPhoneYour Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Best Time to Call You(Required)Select A Time12:00 am12:30 am1:00 am1:30 am2:00 am2:30 am3:00 am3:30 am4:00 am4:30 am5:00 am5:30 am6:00 am6:30 am7:00 am7:30 am8:00 am8:30 am9:00 am9:30 am10:00 am10:30 am11:00 am11:30 am12:00 pm12:30 pm1:00 pm1:30 pm2:00 pm2:30 pm3:00 pm3:30 pm4:00 pm4:30 pm5:00 pm5:30 pm6:00 pm6:30 pm7:00 pm7:30 pm8:00 pm8:30 pm9:00 pm9:30 pm10:00 pm10:30 pm11:00 pm11:30 pmYour Comments/Questions(Required)
