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TYPE OF CONCERN (Please check one):
*
Patient Complaint
Patient Grievance
Date of Incident
*
-
Month
-
Day
Year
Date
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Type of Complaint
*
Treatment
Communication
Access to Care
Billing
Scheduling
Staff Interaction
Other
Location of Incident:
*
Hood River
Mobile Medical Unit
The Dalles
The Dalles Express Clinic
School-Based Health Center
Stevenson
White Salmon
Department:
*
Medical
Dental
Behavioral Health
Lab
Other
I would like a call to discuss this complaint:
*
Yes, please call me.
No, I do not want a call.
Are you the patient?
*
Yes
No
Person Reporting Incident:
*
First Name
Last Name
Relationship to patient:
type here
Phone Number (if different than patient's)
*
Please enter a valid phone number.
Email (if different than patient's)
example@example.com
Name of Patient
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone
Please enter a valid phone number.
Patient Email
example@example.com
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Staff Member(s) involved (if applicable):
Describe the complaint:
*
*
I have attempted to address my concern and am not satisfied with the outcome. Please identify how you attempted to resolve your concerns, with whom, and the reason you are not satisfied:
I have not attempted to resolve my concern because:
Please explain:
How do you suggest the complaint be resolved?
What do you want to happen as a result of this complaint?
Signature of Patient (Individual Filing Complaint)
Date Reported
-
Month
-
Day
Year
Date
Signature of Legal Guardian or Patient Representative
Date Reported
-
Month
-
Day
Year
Date
Submit
Should be Empty: