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Patient Concern Form
To assist Rogue Community Health in addressing your concern, please provide the following information.
Circle Your Clinic or Location
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Medford
Medford – Pediatrics
White City
Ashland
Butte Falls
Eagle Point
Other
Department
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Medical
Dental
Behavioral Health
Integrative Health
School-Based Health Center
Other
Today’s Date
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-
Month
-
Day
Year
Date
Patient Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Best Contact Number
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Please enter a valid phone number.
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please describe your concern? What is your suggested resolution?
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Would you like to change medical providers?
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Yes
No
Patient Signature
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Authorized Representative Signature, if applicable
Clear
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