Client Grievance Form

Client Grievance Form

Please fill out the form below to submit your patient grievance.
Client Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Clients Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Description of the Grievance*
Please be as specific as possible. Include dates, times, staff names, and locations. Use the other side of the form if needed.
Date*

MonthDayYear
Date
Employee Involved

First NameLast Name
Name of Complaint (Check all that apply):*

Quality of CareStaff Conduct or ProfessionalismSchedulingBilling/Financial IssueSafety ConcernOther
Description of Complaint (include details of what happened):*
Desired Resolution*
OFFICE USE ONLY....
Received:Date
Complaint Received By:   First Name   Last Name
Acknowledgement Sent:     Yes     No
Complaint Procedure Completed by:   First Name   Last Name
Complainant Signature:*

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