Family Feedback — Issue, Incident or Concern
Share what happened and how you’d like AccuCare to follow up.
Type of feedback
Concern
Safety incident
Complaint
Compliment
Suggestion
Other
Your full name
*
Your relationship to the patient
Please Select
Parent
Legal guardian
Patient
Other
Patient's name or initials
*
Best contact phone number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email address
example@example.com
Date this happened
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is this an urgent safety issue or was someone hurt?
Yes
No
If this is an emergency, call 911. For an urgent issue, please also call our 24/7 line at (845) 286-9678 — this form is not monitored around the clock.
Nurse or staff member involved (if any)
Please describe what happened
*
What would you like us to do, or how can we make this right?
Preferred way to be contacted
Phone
Email
Either
Best times to reach you
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