Patient Complaint  Form
Circle Your Clinic/Circule su Clinica:
For Quality Assurance Use Only
Patient Account Number:
Notes:
Initials: QA Employee
Date of Resolution:
Department/Departmento:
Name of Patient/Visitor/Nombre del Paciente/Visitante:
Date of Appointment/Fecha (mmddyyyy)
Time/Hora:
Address/Domicilio:
Telephone Number/Numero de telefono:
DOB/Fecha de Nacimiento(mmddyyyy):
Please describe the complaint and include any pertinent information(names and titles, etc.):
Por Favor de dar detalles de su queja. Incluya informacion como nombres, titulos, etc.:
Best time to call/Mejor hora para llamar:  Mon-Fri/Lunes-Viernes:
Patient's Signature/Firma del paciente:
Date:
Staff's Signature & Title:
DOB/Fecha de Nacimiento(mmddyyyy):
Quick Links
QA Director:
Time/Hora:
You have submitted your request!

2670 South White Rd.
Suite 200
San Jose, CA 95148
P: (408)729-9700
F: (866) 931-7822
Administration Office
Promet source logo
Web Accessibility

"To provide high-quality, comprehensive,
affordable healthcare to our community"
Mission Statement
Copyright © 2017 Foothill Community Health Center - All Rights Reserved
FCHC is an FTCA deemed Health center and Federal Public Health Service employee |  Privacy Policy
FCHC logo
Foothill Community
Health Center
ca-health-plus-org