Patient Complaint Form

The care and treatment of all patients should be a priority for all hospitals.  In cases where there is a complaint the hospital needs to avail formswhich enable the patient to documents his or her grievances.  The format of this document is simple but enables accurate truthful recording of information.

Name of the patient: _______________________________________________________

Department concerned with your care: ________________________________________

Patient’s address: _________________________________________________________

Tel: ____________________________________________________________________

Mobile: _________________________________________________________________

Email: __________________________________________________________________

Name of hospital: _________________________________________________________

Address: ________________________________________________________________

Name of chief of staff: ____________________________________________________

Describe your complaint: ___________________________________________________

______________________________________________________________________

Date of complaint: ________________________________________________________

Names of those involved in your complaint:

Name       Position

______________________________________ ______________________________

______________________________________ ______________________________

______________________________________ ______________________________

______________________________________ ______________________________

______________________________________ ______________________________

Name of the person(s) you reported incident to:

Name     Position   Date reported

___________________________ ____________________ __________________

___________________________ ____________________ __________________

___________________________ ____________________ __________________

___________________________ ____________________ __________________

___________________________ ____________________ __________________

Describe the actions you would like taken to address your complaint: ________________

______________________________________________________________________