Confidential Patient Complaint Report

Confidential Patient Complaint Report
We at Valley-Wide Health Systems, Inc. want our patients to receive the best care possible. Please fill out the following form so we can identify areas to improve the care you receive. This patient complaint report will be forwarded to the appropriate Department/Supervisor so it can be reviewed. You will be notified of our course of action if applicable.
I am making this complaint*

As a Valley-Wide PatientOn behalf of a Valley-Wide Patient
Basic Information
Your First and Last Name*

First NameLast Name
Relationship to Patient*
Patients Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Validator*
Date of Incident*

MonthDayYear
Date
Location of Incident*
Nature of Complaint*

Quality of ServiceQuality of CareProfessional ConductIncident
Summary of Complaint/Incident*
Please provide as much detail as possible, include names, dates and locations.
Would you like us to contact you about this issue? Please note that if you DO, you will be required to submit your name and phone number and it will no longer be anonymous.*

YesNo
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

Basic Information