Department of Health

Patient Feedback/Complaint form

INSTRUCTIONS: Any patient may request and complete a paper copy of the Patient Feedback/Complaint form related to the care, treatment or interactions they experience with the Department of Health Healthcare Providers or other staff members.


Complete and submit the information requested on the Patient Feedback/Complaint form. Your feedback is very important to us. The Quality Improvement Director or representative of the Department of Health may contact you to obtain additional information.


The Department of Health will take every step necessary to protect any Personal Health Information (PHI) or Personal Identifying Information (PII) that may be disclosed in the Patient Feedback/Complaint form. The submission of this Feedback/Complaint form constitutes consent to use or disclose any PHI or PII to the minimum number of persons necessary who have a need to know to address any concerns raised in the report.

(Check all that apply)

Location of the incident*

Please select from the pull-down menu. If the location where the incident occurred in not listed, please select "Other".

Please enter the date of service or the date of the incident related to this feedback or complaint.

Enter the first and last name of the person(s) who is/are the subject of the incident report.

Please share your experience or provide information that explains or describes the incident you wish to report. Include the names of any witnesses that may have been involved or seen what happened.

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