Client Complaint Form

Here at Polara Health, WHERE QUALITY MEANS MORE, we CARE about your healthcare experience. Please complete the fields below to the best of your ability. We are here to help.

Today's Date

YYYY

Client's Name

First Name

Last Name

Client's Date of Birth

YYYY

Complainant's Name

First Name

Last Name

Facility

Name of Provider

My complaint is about

Where this happened?

Name, Title and Department (if applicable)

What I feel went wrong

Explain in further detail. Be as specific as possible. Please include any examples you may have to give.

The outcome I would like to see

Phone

(###)

###

####

Client Complaint Form

Services

Crisis

Company

Resources

Support Us

Follow Us