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File a Complaint Against a Facility

Please complete the form thoroughly and describe the issues accurately

What is the Facility's Extension Number (Required)

Give the name and address of the facility

Please Describe your complaint

What actions would you like to see taken?

Your personal information is required to submit this complaint. You may choose to remain 100% anonymous. Your information is secure and will not be shared with anyone unless you give your approval below.


Your Full Name
Street Address
City
State
Zip

Phone
Email
Date of Birth

Do you wish to remain anonymous?	Yes No

May the Patient Quality Foundation Contact You?	Yes No

I, hereby, hold the information provided to be accurate and true to the best of my knowledge. I swear to the information and understand that any false testimony may be harmful to person or persons named in this complaint. I authorize the Patient Quality Foundation to verify the information provided here should there be a need. I waive any and all claims against IndeFree Association, IndeFree Corp., partners and others providing this service for any and/or all damages resulting form incidental or nonincidental means.

I hold the information above to be true and agree to the above.