FORMAL COMPLAINT FORM
This form initiates a formal complaint about Dynamic Functional Solutions Inc.
Full Name
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First Name
Last Name
Contact details (including email):
*
The following information is required in order to help the resolution of your complaint. Please indicate which of the following your complaint is related to:
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Conduct of Health Care Professional(s)
Outcome of Independent Medical Evaluation report
Services provided by Dynamic Functional Solutions Inc.
Other
When and where did the incident related to your complaint take place?
Please describe the incident leading to your complaint.
Please list witnesses to the incident(s) if available.
Submit
Should be Empty: