Online Complaint Platform

Welcome to the McCurtain Memorial Complaint, Compliment and Feedback Portal for Patients and their Families.

Please provide all the required information so we may proceed with the processing of your submission.

Complainant's Information

Please DO NOT disclose confidential, private medical information in this form.
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Please enter a valid phone number.
Email
example@example.com

Patient's Information

Please DO NOT disclose confidential patient information beyond name and Room #.
Patients LAST Name*
Patients Room #

Details of Complaint, Compliment or Feedback

Please be as specific as possible about who, what, when, where, why, etc.
Brief Narration of the Facts:*
Date of Incident:

MonthDayYear
Date
Place / Location:
Images / Files to attach to form:

Upload photo or screenshot of Official Receipt, Sales Invoice or any proof of purchase or transaction (Mag-upload ng larawan o screenshot ng Opisyal na Resibo, Sales Invoice o anumang patunay ng pagbili o transaksyon)
Cancelof

Administrative Use Only: Please detail the investigation into the allegations made here and resolution. Be sure to date and electronically sign each entry.
Should be Empty:

Complainant's Information