Patient Complaint  Form
Circle Your Clinic/Circule su Clinica:
For Quality Assurance Use Only
Patient Account Number:
Initials: QA Employee
Date of Resolution:
Name of Patient/Visitor/Nombre del Paciente/Visitante:
Date of Appointment/Fecha (mmddyyyy)
Telephone Number/Numero de telefono:
DOB/Fecha de Nacimiento(mmddyyyy):
Please describe the complaint and include any pertinent information(names and titles, etc.):
Por Favor de dar detalles de su queja. Incluya informacion como nombres, titulos, etc.:
Best time to call/Mejor hora para llamar:  Mon-Fri/Lunes-Viernes:
Patient's Signature/Firma del paciente:
Staff's Signature & Title:
DOB/Fecha de Nacimiento(mmddyyyy):
Quick Links
QA Director:
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2670 South White Rd.
Suite 200
San Jose, CA 95148
P: (408)729-9700
F: (866) 931-7822
Administration Office
Mission Statement
Our mission is to provide our community with high-quality comprehensive affordable medical, dental, and counseling services at our easily accessible health clinics. Seeing a need to balance the inequalities in healthcare, Foothill Community Health Center provides health services to everyone, regardless of their ethnicity, race, gender, sexual orientation, immigration status, or ability to pay for services.
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