Vision Care Patient Complaint Form
Please use the Vision Care Patient Complaint Form to submit your concerns about vision care services. Your feedback helps us improve our services.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Service (if applicable)
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location or Provider Involved
Type of Concern
*
Please Select
Quality of Care
Staff Behavior
Wait Time
Billing/Charges
Other
Please describe your concern in detail
*
Have you previously reported this concern?
Yes
No
Preferred Method of Contact
Email
Phone
No contact needed
Submit Complaint
Should be Empty: