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MARI Consultation Healthcare Form Complaint
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Healthcare Professional Status
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I would like to collaborate with MARI Consultation
I would like to have a consultation with MARI Consultation about my case
Privacy Policy
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Health/Wellness coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician’s care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.Health/Wellness coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician’s care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.Health/Wellness coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician’s care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.Health/Wellness coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician’s care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.Health/Wellness coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician’s care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.Health/Wellness coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician’s care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.Health/Wellness coaching is not intended to diagnose, treat, prevent or cure any disease or condition. It is not intended to substitute for the advice, treatment and/or diagnosis of a qualified licensed professional. Trained Health Coaches may not make any medical diagnoses, claims and/or substitute for your personal physician’s care. As your health/wellness coach I do not provide a second opinion or in any way attempt to alter the treatment plans or therapeutic goals/recommendations of your personal physician. It is my role to partner with you to provide ongoing support and accountability as you create an action plan to meet and maintain your health goals.
I agree to the privacy policy.
Healthcare Professional Type:
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Physician
Nurse
Pharmacist
Others: Please specify….
Healthcare Professional Type
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Licensed
Please Choose
Yes
No
in which country? (the number of countries can be more than one)
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United States
United Kingdom
Canada
Australia
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Choose US-State :
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Choose Canadian Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
What is Your State/Province
License Number
Add
Remove
For each country type your License number
Title
*
Title
Dr.
Miss.
Mr.
Mrs.
Ms.
Prof.
Rev.
Sr.
First Name
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Middle Initial
Last Name
*
Suffix
Date of Birth
*
MM slash DD slash YYYY
Gender
*
Please Choose
Male
Female
Other
Gender
*
Marital Status
*
Please Choose
Married
Single
Divorced
Life Partner
Separated
Widowed
Other: Please specify…
Marital Status
*
Language
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English
Other: Please specify
Please specify your language:
Race
*
Please Choose
Black – Non-Hispanic
White – Non-Hispanic
Hispanic
Asian / Pacific Islander
American Indian/ Alaskan Native
Other
Race
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Home Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Primary Phone (Cell or Home)
*
Secondary Phone (Optional)
Personal Email Address
*
Work Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Work Phone
Other (Optional)
Secondary Work Phone
Pager
Fax
Secondary Work Phone
Pager
Fax
Work Email Address
Are you affiliated with any hospital?
No
Yes
Hospital Name
Hospital Address
Same as previous
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Hospital Phone
Other (Optional)
Secondary Work Phone
Pager
Fax
Secondary Work Phone
Pager
Fax
Hospital Email Address (optional)
Employment Status
Please Choose
Active Duty Military
Employed Full-Time
Not Employed
Student Full-Time
Child
Employed Part-Time
Retired
Student Part-Time
Disabled
Homemaker
Self Employed
Other
Employer (Optional)
Employer Phone (Optional)
Preferred Mode of Communication
How would you like MARI Consultation to communicate with you?
Telephone
Email
Regular mail
Email
Fax (If confidential line)
YOUR ISSUE IS ABOUT:
Please Choose
Your Patient
A Patient (Not yours)
A Healthcare Professional (e.g. Physician, Nurse, Pharmacist, etc.)
A Commercial Business (e.g. Distribution Medical Supply Company, Advertising Company, etc.)
Other:
Please specify:
NATURE OF COMPLAINT
Please write about the nature of complaint, i.e. whether your complaint is about a behavior, business activity, or a lawsuit file from your patients or colleagues.
Person/Business's full name
Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date(s) attended
MM slash DD slash YYYY
Occured at a
Office
Hospital
Other
Have you tried Speaking with this Person/Business about your concern?
Yes
No
Relief Sought
Please Describe what would you like to see happen as a result of this complaint
DETAILS OF COMPLAINT
State your complaint in chronological order and in detail. In addition, please include dates of treatment and list all relevant treating providers specific to your complaint. It is important that you be specific regarding any allegations of substandard care. Providing a comprehensive narrative of your complaint allows for a more expeditious review process.
Write about your interest and why you would like to collaborate with MARI Consultation:
Do you have any experience of medical law or similar knowledge?
Please write in detail
Do/Did you have any medical law-related case that you would like to solve it through our expert team, in the meantime?
How and in which level, you are able to be involve and collaborate with MARI?
How is you free time?
Documents and Attachments
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