Online doctor complaint form

An accurate and detailed complaint will help the reviewing physician to respond appropriately to your concerns. To facilitate the review and ensure an appropriate response, it is strongly recommended to file a separate complaint for each physician involved.

Si vous avez besoin d’aide pour rédiger votre ou vos plaintes, vous pouvez communiquer avec le Centre d’assistance et d’accompagnement aux plaintes (CAAP-Outaouais) de l’Outaouais par téléphone au 819 770-3637 ou par courriel à info@caap-outaouais.ca.

Veuillez noter qu’un accusé de réception, de même qu’une copie du formulaire complété, seront envoyés automatiquement aux adresses courriels que vous inscrirez dans le formulaire de plainte.

* = Required field

User information

Person receiving care and services

Last Name *

First Name *

Date of birth *

Address *

Postal Code *

Email *

City *

Phone number *

Complainant information

Person writing the complaint, only if different from user

I am the user's representative *

I have the user's authorization to make the complaint *

Last Name *

Address *

Postal Code *

Email *

First Name *

City *

Phone number *

Nature of representation *

Complaint

Doctor's name

Specialty

Where did the incident occur?

Department name

Date and time of incident

Description of incident

Describe in details the incident by answering these questions: Who did what? Where? When? How?

State your expectations in the treatment of this complaint *

Divulgation Autorization

I hereby authorize the Medical Examiner to divulge this complaint to the concerned doctor, only for its examination. Strict confidentiality will be upheld during the entire length of the examination process.

Signature

Please be advised that the Service Quality and Complaints Commissioner will forward your complaint form to the Office of the Medical Examiner upon reception

Signature *

Please check this box as proof of signature on the form

Date *