Patient Concern Form

All patient complaints and concerns are confidential. This report and any attachments are part of Bond Clinic, P.A.’s Quality Improvement Program and therefore protected confidential documents under the law. All complaints/concerns will be given serious attention. Once submitted, this form will be forwarded to the appropriate Bond Clinic, P.A. representative to address your concerns.

PERSON REGISTERING THE CONCERN

First Name*

Middle Name*

Last Name*

Mailing Address*

City*

State*

Zip*

Phone Number*

Email Address*

Relationship to the Patient*

PATIENT INFORMATION

Patient First Name*

Patient Middle Name*

Patient Last Name*

Patient Mailing Address*

City*

State*

Zip*

Patient Date of Birth*

Patient Phone Number*

Patient’s Primary Care Physician*

NATURE OF CONCERN

Date the Incident Occurred*

Time*

Department(s) Involved*

Name of Team Member Involved*

Please check the circle that best describes the nature of your complaint/concern and provide details below*

Substandard Care (Misdiagnosis, Negligent Treatment, Delay in Treatment, etc.)Unprofessional Conduct (staff/physician)AccessBilling / Registration ConcernOthers

Describe problem or reason for complaint*

Patient/Complainant’s Signature*

Date*

Patient Concern Form

PATIENT CONCERN FORM

PERSON REGISTERING THE CONCERN

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