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MARI Consultation Patient Compliant

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Patient Status

MM slash DD slash YYYY
Address
Other Phones (Optional)
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

MM slash DD slash YYYY
Address
Other Phones (Optional)
Preferred Mode of Communication
How would you like MARI Consultation to communicate with you?
NATURE OF COMPLAINT (Check all that apply)
Details of Physician
Physician Full name
Address
City
Postal Code
Phone
Date(s) Attended
 
Occured at a

Have you tried speaking with this physician about your concern

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.
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.