Patient Complaint and Grievance Form

Patient Complaint and Grievance Form — Form Fields

This healthcare template includes 9 fields. Allow patients or family members to formally submit complaints or grievances about their care experience. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Service (text, required)
• Contact Email (email, required)
• Contact Phone Number (text, required)
• Department or Service (dropdown selection, required) — options: Emergency, Primary Care, Specialist Clinic, Inpatient, Surgery, Pharmacy, Billing, Other
• Nature of Complaint (dropdown selection, required) — options: Quality of care, Provider communication, Staff conduct, Wait time, Billing issue, Privacy concern, Facility issue, Other
• Please describe the incident or concern in detail (long text, required)
• Have you raised this concern with the department directly? (multiple choice, required) — options: Yes, No
• What resolution are you seeking? (multiple choice, optional) — options: Apology, Explanation of what happened, Change in care process, Refund/billing correction, No specific outcome