Patient Concern Form

Note that we will not use any information submitted through this form to send you promotional material.

Name

First Name

Last Name

Contact Email

Contact Phone Number

(###)

###

####

Attending Provider

First Name

Last Name

Location (if applicable)

Description of Grievance

Please provide as much detail as possible.

Desired Outcome

Please describe the resolution you are seeking.

Signature

By checking this button, I assert that the information provided is accurate to the best of my knowledge, and I acknowledge that ClearTMS+ will review my grievance in accordance with its grievance policy.

A agree with the above statement.

Date of Signature

MM

DD

YYYY

The Clear TMS Grievance committee will meet within 2 days business days after receiving this communication and will respond within 5 business days.