Enquiry / Feedback - Patient

We value your feedback and encourage you to submit your concerns, thoughts or praises using the form below.

Note:  * indicates a required field

*Name

*Phone

*Email

Reason for contact

Compliment Complaint General Enquiry Lake Images App

Location/Region of interest

Ballarat Region Geelong Region Western Region Melbourne Region Warrnambool Other

*Message

Preferred contact method

Phone Email No follow up contact required

*Security Check

Enter the text in the image above.