Patient Complaint Form

Patient Complaint Form

Instructions: Please fill out this form in its entirety and submit to be processed. A member of our team will get in touch with you. Thank you!
Please list the Clear Lakes Dental clinic location you would like to file this complaint for:

Location

Street Address Line 2

CityState

Zip CodeCountry
Please select the Clear Lakes Dental location you would like to file this complaint for:*
Patient Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Patient Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient Phone Number:*
Please enter a valid phone number.
Patient Email:*
example@example.com
Are you the patient?*
If no, please state your first & last name, along with your relation to the patient:
Please state your first and last name:
Nature of Complaint:*
Please limit to 100 words or less
Name(s) of Clear Lakes Dental team member(s) involved or physical description:*
By signing this complaint form, I request that the headquarters of Clear Lakes Dental resolve my complaint. I will provide any and all information and cooperate in helping the headquarters of Clear Lakes Dental resolve my complaint. To the best of my knowledge, this information is true and accurate.
Signature of Patient:

Clear
Today's Date:

MonthDayYear
Signature of Complainant: (if different from patient)

Clear
Today's Date:

MonthDayYear
Should be Empty: