Dr. Flett’s Paediatric Feedback Support Form

Note: Please ensure all information is accurate before submitting. Thank you for your valuable feedback!

Date
DD slash MM slash YYYY
General Information:
Date of Last Appointment with Dr. Flett*
DD slash MM slash YYYY
Email*
Child's Name*
First Last
Parent's Name*
First Last
Date of Birth*
DD slash MM slash YYYY
Feedback Details*
Briefly Describe the Problem and Reason for the Feedback:
Medication Information
List of Medications Your Child is Taking*
Name of Medication
List of Medications Your Child is Taking*
Dosage Amount
List of Medications Your Child is Taking*
When the Medication is Taken (e.g., Morning, Evening, etc.)
Potential Side-effects Experienced (if any)*
Progress on Medication (if applicable)*
Feedback From School
Feedback from the Teacher (if applicable)*
Feedback From Home
Feedback from Parent or Caregiver (if applicable)*
Additional Information
Any Other Details or Concerns*
Type of Health Condition*
- General Health Condition
- Acute Health Condition
- ADHD, school, behaviour, mood, learning.
Note: Please ensure all information is accurate before submitting. Thank you for your valuable feedback!

General Information: