MARI Consultation Patient Compliant

Patient Status

I AM THE PATIENT

I AM REPRESENTING THE PATIENT FOR THE PURPOSE OF THE COMPLAINT

Title*

First Name*

Middle Name

Last Name*

Nickname

Date of Birth**

Gender *

Relationship with the Patient *

Relationship with the Patient

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Language *

Language*

Primary Phone (Cell or Home) *

Secondary Phone (Optional)

Other Phones (Optional)

Work

Pager

Fax

Work Phone (Optional)

Pager Phone (Optional)

Fax Phone (Optional)

Email Address

Privacy Policy*

I agree to the 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.

Patient Status

Title*

First Name*

Middle Name ( Optional )

Last Name ( Reqired )*

Nickname / AKA ( Optional )

Date of Birth*

Gender *

Marital Status *

Marital Status

Language *

Language*

Race *

Race*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone (Cell or Home) *

Secondary Phone (Optional)

Other Phones (Optional)

Work

Pager

Fax

Email Address*

Employment Status *

Employer (Optional)

Employer Phone (Optional)

Preferred Mode of Communication

Telephone

Email

Regular mail

Email

Fax (If confidential line)

How would you like MARI Consultation to communicate with you?

RELIEF SOUGHT

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.

DETAILS OF COMPLAINT

Documents and Attachments

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.

CAPTCHA