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Confidential Complaint & Incident Report Form
This form allows patients, coordinators, and surgeons to file a confidential report regarding unethical behavior, misconduct, or violations of program standards.
Reporter Identification
Please Select
Patient
Surgery Coordinator
Surgeon
Recovery House Rep
Other
Who Are You?
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Would you like to remain anonymous ?
Yes, I would like to remain anonymous
No, you may contact me for follow up
Date of Incident
-
Month
-
Day
Year
Date
Location of Incident
Involved Person(s)
Relationship to you (Doctor, Coordinator, Etc)
Was anyone harmed or at risk?
Yes
No
What happened?
Upload your evidence
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Select all that apply!
False advertising or misleading pricing
Patient endangerment or medical negligence
Unlicensed / Unqualified Personnel
Confidentiality Breach
Fraud or theft
Verbal / Physical Abuse or Harrassment
Bribery or Comission Scheme Abuse
Social Media Misconduct or Defamation
Violation of Coordinator Code of Ethics
Violation of Recovery Home Safety Protocols
Other
What would you like us to do in response?
How would you like us to respond?
Please Select
Investigate
Just informing
Revoke Certification
Mediate
No Action Needed
Signature
Submit
Should be Empty: