Patient Information

Patient Compliments & Complaints

Various medical supplies and sample health cards

Patient Compliments and Complaints

Please use this form to share your complaints or compliments regarding the ESFHT. Please note, this form is not intended for medical advice or assistance. We do not monitor this account every day. For any non-emergency concerns please contact the office at 519-322-1100. For immediate medical assistance please dial 9-1-1.

Compliments & Complaints

*Date:

*Name of Client/Family Member(s):

*Address:

*City:

*Postal Code:

*Can we contact you at? :

Can we contact you at? HomeCell Other

*Home Phone#:Phone PrefixPhone Line NumberPhone Extension

ext.

*Cell Phone# :Phone PrefixPhone Line NumberPhone Extension

ext.

*Other:Phone PrefixPhone Line NumberPhone Extension

ext.

*Can we identify ESFHT? :

Can we identify ESFHT? YesNo

Relationship with ESFHT:

Relationship with ESFHTPatient
Family/significant other
Other

Site / Program: :

Compliment

Please share your compliment with us::

Complaint

Please describe your complaint/concern in detail (date, time, individual(s) involved, specific concern - use back of page if necessary)::

What can we do to address your complaint/concern?:

Patient Information

Patient Compliments and Complaints

Compliments & Complaints

Compliment

Complaint

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Patient Information

Patient Compliments and Complaints

Compliments & Complaints

Compliment

Complaint

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Urgent Care Appointments

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Community Calendar

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Please do not press back or refresh.

Urgent
Care Appointments

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Doctor