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NORTH CAROLINA STATE BOARD OF DENTAL EXAMINERS 2000 Perimeter Park Drive Suite 160 Mooresville, NC 27560 (919) 6788223 COMPLAINT FORM INSTRUCTIONS 1) Please fill in the information listed below. Then

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How to fill out complaint form - patient

How to fill out a complaint form - patient:

01

Start by carefully reading the instructions provided on the complaint form.

02

Provide your personal information such as your full name, address, date of birth, and contact details.

03

Indicate the date and time of the incident or issue that you are filing the complaint about.

04

Clearly state the nature of your complaint, providing as much detail as possible.

05

If applicable, mention the names of any individuals involved in the incident or issue.

06

Attach any relevant supporting documents or evidence that can help substantiate your complaint.

07

Sign and date the complaint form to validate your submission.

Who needs a complaint form - patient?

A complaint form is specifically designed for patients who have experienced an issue or incident that they wish to address formally. It is suitable for any patient who wants to bring attention to a problem or concern regarding their healthcare, treatment, or the conduct of healthcare professionals. Whether it's a mishandled procedure, misdiagnosis, substandard care, or any other aspect causing dissatisfaction, patients have the right to fill out a complaint form to communicate their grievances effectively. It allows patients to voice their concerns and seek appropriate resolution or redressal.

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What is complaint form - patient?

A complaint form for patients is a document used to report grievances or issues with the healthcare services or treatment received.

Who is required to file complaint form - patient?

Patients who have experienced negative or unsatisfactory experiences with their healthcare providers or facilities are required to file a complaint form.

How to fill out complaint form - patient?

Patients can fill out a complaint form by providing their personal information, details of the incident or issue, and any supporting documentation.

What is the purpose of complaint form - patient?

The purpose of a complaint form for patients is to formally document and address any concerns or complaints they may have about their healthcare experiences.

What information must be reported on complaint form - patient?

Patients must report details of the incident, date and location of occurrence, names of healthcare providers involved, and any other relevant information.

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