Capitol Ear, Nose and Throat
3100 Blue Ridge Road, Suite 201
Raleigh, NC 27612
Tel:(919) 787-1374
Fax : (919) 787-8870
www.capitolent.net

Patient Privacy Complaint

   Date: _________________________

   Patient Name: __________________________________________________________             
   
   Date Of Birth: _________________

   Name (if different than patient):______________________________________________
 
   Relationship to patient: ____________________________________________________

   Contact Phone: _________________

   Description:_____________________________________________________________
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   Suggestion for improvement in security and/ or what you 
   feel we should do: _______________________________________________________ 
   _______________________________________________________________________
   _______________________________________________________________________  
   _______________________________________________________________________
   _______________________________________________________________________

    Thank you ! Your suggestion is our opportunity. 


    ************************************** For Office Use Only *************************************
   
   Received by: ____________________________________________________________

   Date Received: _________________

   Action: _________________________________________________________________
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