Complaints

In order to lodge a complaint, please fill in the below form. After this is received, a Consent form will be automatically emailed to you. Please complete the Consent form and either scan and email back to the College office or mail the hard copy to the College office. Once both documents have been received, your complaint will be sent to the physician for their response. The physician has 30 days to respond and if they do respond, this will be forwarded to you. After this, the Registrar will review the information and decide the next step.

If you have any questions, please contact us.

Patient Information

Name(Required)

Prefix First Last

Health Card #(Required)

Birth Date(Required)

Address(Required)

Street Address Address Line 2 City Province Postal Code

Tel. Home(Required)

Cell(Required)

Email(Required)

Person Making Complaint

Is the contact information of the person making the complaint the same as the patient above?(Required)

Yes

Relationship to Patient(Required)

Name(Required)

Prefix First Last

Address(Required)

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

Email(Required)

Tel. Home(Required)

Doctor Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City Province Postal Code

Office Tel(Required)

Your complaint (please include as much detail as possible with dates.)

I would like to lodge a complaint against Dr.(Required)

Signature of complainant(Required)

Print Name(Required)