Patient Concern Form

 


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

PATIENT INFORMATION

NATURE OF CONCERN



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