I am a Patient

Full Name*

Preferred Name

Pronouns

Mailing Address*

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

Email

Home Phone*

Mobile Phone

I would like to receive correspondence from the College by:*

Email

Letter Mail

Physician's Full Name*

If you are filing a complaint against more than one physician, please complete a separate complaint form for each physician.

Where Did the Incident Take Place? (clinic, hospital, office, etc.)*

Incident Date(s)*

Description of the Incident

Please be as detailed as possible and provide information in paragraph form.

Please indicate the exact action(s) that the physician did OR did not do that is causing you to make this complaint. This summary is required to help the College better understand your concerns and process your complaint efficiently.

Concern 1*

Concern 2 (if applicable)

Concern 3 (if applicable)

Family Physician or Primary Care Provider (Full Name)

Additional Documents

If applicable, please list any additional information (i.e., written correspondence, audio recording, etc.) in your possession, that may be relevant to your complaint. The College's investigator will contact you if the additional information is necessary for their investigation.

Witnesses

List any people who may have information about this complaint. You are not required to have a witness to make a complaint. NOTE: Please ensure that each witness is aware that the College may contact them as part of the investigation of your complaint.

Witness Name

Witness Contact Info (phone/email)

Connection to Patient/Complaint

How They Were Involved

Witness #2 Name

Witness #2 Contact Info (phone/email)

Witness #2 Connection to Patient/Complaint

How They Were Involved

Follow-up Action

Describe any steps you may have taken to resolve your complaint.

Follow Up Action

I declare that I am the person identified as the "complainant" and that I am making a formal complaint against the physician named in this form.*