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AMS Complaint Form
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2022-08-01T02:05:27+00:00
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Date of Complaint
*
Date
Complainant Name
*
First
Last
Are you:
*
Walk In Client
Client With Appointment
Service Provider
Visitor
Staff Member
Other
Which service did you receive today?
*
Medical
Dental
Mental Health
Drug & Alcohol
Public Health
Other
Complainant Address
*
Complainant Phone Number
*
Complainant Email Address
*
Staff Member who received the Complaint
*
Name
Nature of Complaint
*
Please explain above the incident that happened/complaint you would like to report against the staff/team member
Would you like us to contact you regarding the complaint?
*
Yes
No
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