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Online Complaint Intake

Fields marked with * are required

Contact Information:

Your First Name

Your Last Name




State (e.g. PA)

Zip Code (e.g. 17000)

Phone Number (e.g. 555-555-5555)

Alternate Phone Number (e.g. 555-555-5555)


Complaint Type



Confidentiality Requested - will allow DOH to be in touch regarding outcome of investigation, facility will not be informed who lodged the complaint.

Relationship to Patient


Please specify if "Other":

Patient Information:

Patient First Name

Patient Last Name

Patient Date of Birth (e.g. MM/DD/YYYY)

Date of Incident (e.g. MM/DD/YYYY)

Facility Information: 

Facility Name*

Facility Address*


Facility City*

Facility State* (e.g. PA)

Facility Zip Code* (e.g. 17000)

Complaint Information: 

Concerns discussed with:

Details (Please be as specific as possible)*