Note

• This form may take 10 - 15 minutes to complete.
• Fields with * are compulsory.

I confirm that the information provided above is true and correct. I understand that any false or
misleading information provided by me may constitute an offence under Section 182 of the Penal Code.

I understand that the information provided by me may be used, retained and disclosed by MOH, including
(but not limited to) for the purposes of investigations, proceedings and other regulatory actions by MOH.
Without limiting the foregoing, I understand that some or all of the information provided by me may be
disclosed to other parties including (amongst others) the person/ shop/ company that is the subject of this
feedback and/or other government agencies.

I further understand that I may be required to give a formal statement to MOH, in person, in relation to
my feedback and/or other matters within my knowledge.