Patient Complaint Form

Patient Complaint Form
We value our relationship with you and appreciate your taking the time to inform us of your complaint. We are committed to responding to concerns promptly.

To file a complaint, please complete the form below. The office manager may reach out to you for more information about your concerns. The practice owner will be notified and the concern will be thoroughly investigated. We will respond to your complaint within 30 days.
Patient Information
Name*

First NameLast Name
Date of birth*
Name of person filling out form, if different than patient

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of incident*
Name of staff involved, if known/applicable
In your own words, please identify your complaint or concern:*
As a result of your complaint, what would you like to see happen? What would resolution look like for you?*
I understand that staff investigating this complaint may need to see and review health records, but that all information will be kept confidential. I further understand that this complaint/grievance will in no way affect any care provided.
Signature*

Clear
Date*

MonthDayYear
Date
Thank you for taking the time to bring your complaint to our attention. You should receive a response within 30 days.
Should be Empty:

Patient Information