Confidential Patient Complaint Form printable pdf download

CONFIDENTIAL

PATIENT COMPLAINT FORM

All patient complaints are confidential. This report and any attachments are part of NJGREENMD and therefore

protected confidential documents under the law. All complaints will be given serious attention. This patient complaint

form will be forwarded to the Practice Manager, who will directly address your concerns.

Person Making Complaint

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

Phone: (

) ________-___________ What is a good time to reach you: _____________________________

Complaint received by: ______________________________________________________________________

Nature of Complaint:

Date of Complaint: _____________________

Did the incident involve a staff member ?

(Name of staff member): __________________________________________________________________

Describe problem or reason for Complaint: _______________________________________________________

__________________________________________________________________________________________

Client’s Signature:________________________________________ Date: ____________________

__________________________________________________________________________________________

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(If this complaint was taken via phone, please check here)

Confidential Patient Complaint Form