voice Your complaint

All your information will be forwarded to a Vaad representative who will contact you directly.

Fields marked with an * are required to process your form.

We recommend that you print out a copy of this form after completion but before submission.

* Name:
* Address:
* Phone:		Fax:
E-mail:
* Patient's Name:		Relationship:
* Date Admitted:		Date Discharged:
Patients Room & Bed #: (if patient still hospitalized)
* Health Facility:		Department:
Physician:
Date of Occurrence:		Time of Occurrence:
Name & Title of the Wrong Doer:
* Nature of Complaint: Administration   Medical Nursing Food Service Volunteer Services Courtesy Communication Professionalism Pastoral/Religious Needs Housekeeping & Maintenance
* Details of Complaint:
Response to your complaints (if any):