Advocacy-Complaint Form

Medical Advocacy/Complaint Form
Today's Date

MonthDayYear
Date
Name of Person Making the Complaint:

First NameLast Name
I can be contacted at:
Please enter a valid phone number.Format: (000) 000-0000.
Or Email Address:
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
The best time of day to reach me is?
Consent to disclose my name: (Please indicate one of the following)
Information & Area Regarding - Suspected Complaint

Other
Please provide a detailed description of your complaint covering who, what, when, where, how, and why of what happened.
Do you have witnesses?
Witness Name

First NameLast Name
Witness Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Witness Phone
Please enter a valid phone number.Format: (000) 000-0000.
I hereby electronically submit the following document to The Dot Lake Village Council on the behalf of {nameO} on the date of {todaysDate}
Do you have any files to upload? If so, upload them here.

Cancelof
Signature
Should be Empty:

Medical Advocacy/Complaint Form