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MARI Consultation Healthcare Form Complaint

 

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Healthcare Professional Status*

Privacy Policy*
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.
License Number
For each country type your License number
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Home Address
Work Address
Other (Optional)
Are you affiliated with any hospital?
Hospital Address
Other (Optional)
Preferred Mode of Communication
How would you like MARI Consultation to communicate with you?

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.
Address
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Occured at a
Have you tried Speaking with this Person/Business about your concern?
Please Describe what would you like to see happen as a result of this 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.
Please write in detail
Attach a copy of all documents here you can add up to 20 files with JPEG, gif, PNG, PDF, Docx formats. size limitation per file is 5Mb
Drop files here or
Accepted file types: jpg, gif, png, pdf, , docx, Max. file size: 5 MB, Max. files: 20.
    Any other people/business
    Name
    Contact Information
    Their Role / why they might have information to contribute
     
    Please refer us any other people/business who you would think that might be interested in working with us or may need a consultation with us.