Submit a Complaint

Please make sure you provide an email address and phone number (or both) as we are unable to reply directly to these form submissions. We will acknowledge receipt of your complaint within two working days and provide more information about the complaint process. If you are having any issues completing this form, please contact the Service User Feedback team on 028 9040 0999 (Mon-Fri 9am to 5pm) or via email at complaints@nias.hscni.net.

Incident Date

(If you do not know the date, please add a date you think is close)

Your Name(Required)

First Last

Phone

Email(Required)

Enter Email Confirm Email

Are you completing this form on the behalf of the patient/does your feedback relate to another individual?

Yes

N/A

To complete a Third Party Consent Form click here. To complete a Consent Form for an Elected Representative click here.

Patient's Name

(if different)

First Last

Patient's Date of Birth

(please fill in this if your feedback relates to patient care)

Address/Location of the Incident

Address Address Line 2 City/Town County Post Code

How would you like us to contact you to thank you for your feedback and advise you of the next steps?

Phone

Post

Is the patient aware that you're providing this feedback on their behalf?

Yes

N/A

Details of your complaint(Required)

As a result of this feedback, what action would you like taken forward?

Information about the way we use this data can be found in our privacy notice

Name

This field is for validation purposes and should be left unchanged.