Patient Complaint Form
KCS Health Center is dedicated to delivering the highest level of care to our patients. Please complete this form if you have any concerns about the healthcare of treatment that you or a family member are receiving or if there were any instances where care was not provided.
Patient Information
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Location of Complaint
*
Please Select
Orangethorpe Clinic
Lincoln Clinic
MacArthur Clinic
Commonwealth Clinic
Caballero Shelter Clinic
Nature of Complaint:
*
Appointment
Medical Care
Medication
Referral
X-ray
MRI
Policy/Procedure
Ultrasound
Lab Results
Follow-Up
Other
If other, please specify
Problem with:
*
Provider
Medical Assistant
Health Navigator
Call Center
Front Reception
Administration
Other
If other, please specify
Date of Incident
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Name of Staff Involved (if known):
Details of Complaint/Grievance
*
Would like to be followed up with via:
*
Phone
Letter
No follow-up needed
Signature
*
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Save
Submit
Should be Empty: