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Garrison Creek
Bathurst
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Patient Complaint or Concern

Your First and Last Name
Your Address (Street, City and Postal Code)
Yoiur Email
Best phone number to reach you at
Patient Name & Address (if other than the person registering complaint)
Details of complaint. 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
Any other comments?
Do you consider this matter to be urgent?
Yes No