Healthy People. Healthy Families. Healthy Community.

Patient Feedback Form

Please share with us comments and suggestions to help us continue to improve our services and quality of care. Comments are greatly appreciated, as our staff work very hard to serve you. It’s important to know what we are doing well, so that we may continue to do so.

We’re always open to helpful suggestions. You are welcome to submit a complaint when you feel that you need assistance in addressing a concern or resolving an issue.

Patient Info

Patient Name

First Name

Last Name

Patient Email

Patient Phone

(###)

###

####

Patient Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Comment / Incident Details

Type of feedback

Date of incident

YYYY

CTHP personnel involved

Describe the event

Your preferred resolution (if this is a complaint)

Preferred methods of contact

Phone

Mail