Complaints – Kingston Community Health Centres

Name of Complainant*

First Last

Complainant is*

Address

Street Address Address Line 2 City Province Postal Code

Phone

Interpreter Required?

Language

Problem/concerns*

(Briefly describe the complaint or concerns)

What would you want done?*

Name of Person Making Complaint*

First Last

Name and phone number of person making the complaint, if doing so on behalf of the complainant mentioned above