Patient Complaint Form – Virgil Site

Your First and Last Name (required)

Address (Street, City and Postal Code) (required)

Your Email (required)

Best phone number to reach you at (required)

Patient Name & Address (if other than the person registering complaint)

Name of Family Physician (required)

Details of complaint (required)
*Please describe your complaint/concern in as much detail as possible including date of occurrence.

Name of healthcare team member(s) involved

Describe any efforts that you have made to resolve this matter

Please describe the result or outcome that you would like to see (required)

Any other comments?

Do you consider this matter to be urgent?


Complaints will be reviewed and investigated. We will acknowledge receipt of your complaint.
Please note, anonymous complaints will be disregarded.