Complaint & dissatisfaction

This form allows patients of the Clinique THVR to submit a complaint or express dissatisfaction
regarding a service received. Your comments help us improve the quality of our care. All
complaints will be treated confidentially.

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1. Information about the person filing the complaint

NAme *

Prénom

Nom

Date of birth (day-month-year):

Adress:

the known): or

City:

Zip code:

State:

Phone:

Email: *

2. Are you the person who received the services?

2. Are you the person who received the services?

• Yes
• No

(if no, specify your relationship to the patient):

3. Information about the service or person concerned

Date or period of the incident:

Name of the professional or service concerned (if known):

Location or context of the situation:

4. Description of the complaint or dissatisfaction

Please describe clearly what happened (add a sheet if necessary):

5. Desired outcome or patient's expectations

I am informing you of the situation to express my dissatisfaction...

Checkboxes

• ...but I do not wish to pursue the matter further.
• ... and I would like to receive follow-up.

6. Authorization and consent

I consent to the information provided in this form being used by THVR Clinic to assess and process my complaint, in accordance with privacy laws. I authorize email communications in follow-up to this request.

7. Signature

Clear Signature

Date

Envoyer