Feedback Form

(to be completed by the client/client’s family member/caretaker)

United Indian Health Services, Inc. welcomes all feedback as an opportunity to improve services. All clients have the right to give feedback related to the delivery of health care for any service at any of our sites. Completing this form will not compromise access to future care.

Complaint Form

*Name

First Last

*Name optional – if your feedback is related to your care, omitting your name could limit our ability to fully investigate the issue or come to a resolution on your behalf

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Daytime Phone

Date of Birth

Section and site where incident occurred

Feedback

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