Complaint Form

COMPLAINT FORM
This form is to be used for any dissatisfaction or concern regarding World Health Clinicians dba Circle Care Center. The complaint may be directed towards a specific employee, a provided service or the organization as a whole.

Our management and staff respect the right of members of the community to complain about the standard of services that we provide. Our commitment to fair, equitable and timely resolution of complaints is described in our Complaint Policy. You may request a copy if desired.
Date

MonthDayYear
Date
Name of Person Submitting Form
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Email
example@example.com
What is the nature of your complaint?
What documents should we review in considering this complaint?
Who else might have information about the complaint?
WE WILL ACT ON YOUR COMPLAINT IN A PROMPT MANNER AND WE WILL ADVISE YOU OF ITS OUTCOME
Phone: 203-852-9525

Fax: 203-854-0371

www.circlecarecenter.org
Should be Empty: