INSTRUCTIONS:
The Family Health Centers, Inc works to ensure that all patients get the best care possible.  We take your concerns seriously and would like to get additional information to help us with your complaint.  All patient complaints are confidential. Our complaint resolution process begins with the gathering of important information from all involved parties. Provide as much information as possible. All complaints will be given serious attention.  This patient complaint form will be forwarded to the appropriate Manager, who will directly address your concerns.

* 1. PERSON MAKING COMPLAINT

* 2. Your Relationship to the Patient

* 3. What is a good time to reach you

NATURE OF COMPLAINT:

* 4. Date of Complaint

Date
/
/

* 5. Time of Complaint

Date / Time
:

* 6. Staff Involved (Name/Title):

* 8. Department Involved:

Description of Complaint

* 9. Describe problem or reason for Complaint:

T