Patient Complaint Form

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Patient Complaint Form

We are sorry to hear that you have an issue with Well Life Medicine. We would like to hear about this issue and if possible help resolve it.

If this is an urgent issue please reach out to our clinic manager Aliesha Sampson at asampson@welllifemedicine.com or 971-301-4411 ext 107

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* Indicates required question

Patient's Full Name *

Your answer

*If not the patient what is your name and relation to the patient?

Your answer

Date of Birth *

MM

/

DD

/

YYYY

Telephone Number *

Your answer

Detail the complaint below, please include date, times, and names of practice personnel if known. *

Your answer

Is it okay to contact you in regards to this complaint? *

Yes

No

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