printer friendly

send to a friend

Text Size

A- A A+

Documentation of Customer Concern

Moundview Memorial Hospital & Clinics encourages our patients and visitors to let us know how we can improve our services. A formal process is in place for investigating and resolving customer concerns. If you are unhappy with our services and our staff is unable to immediately resolve your grievance, please complete a customer concern form by clicking on the link below. Once received, the forms are forwarded to the appropriate manager. Resolution of the complaint should generally occur within two weeks. This includes investigating the concern, initiating a corrective process to resolve the issue and follow up with the patient and/or family.

Customer Concern Form

Note: The form is presented to you in a fully encrypted format, just like an online store. This means that no one other than MMH&C administration will be able to read your message.

All information requested is optional

Patient Name
Please let us know your name.

(if willing to provide)

Date of Incident/Concern:
Invalid Input

Person Submitting This Concern:
Invalid Input

If "other", please specify
Invalid Input

If "other", please specify
Invalid Input

LETTER TO BE SENT TO To guarantee follow up of your concern, please provide your name and address. We will mail you a letter acknowledging your concern and our plans to resolve it. If you prefer not to be contacted, you may leave this information blank.

Name
Invalid Input

Address
Invalid Input

Your Email
Please let us know your email address.

City
Please write a subject for your message.

State
Invalid Input

Zip
Invalid Input

Please state your concern/complaint:
Invalid Input

Please give a concise, plain statement of the resolution you seek for your complaint:
Invalid Input

Click here to send your concern ->