Patient Feedback Form


Chapa-De practices a philosophy called the “Patient-Centered Health Home.” This means that we want you to have consistent communication with your primary care provider and the healthcare team that supports you. We will do our best to make sure that you see the same healthcare team at every visit, so that you become comfortable with us and we understand you. We want to help you set your own health goals, and then help you work to accomplish them.

An invaluable element of understanding our patients, is the ability to gather patient feedback. Whether you, as a patient, have complaints or compliments, Chapa-De will use that information to better their quality of service to all of its patients.

Please fill out the form thoroughly if you have a compliment, have a complaint, or would like to request a different doctor. If you are submitting a complaint or request to change providers, a member of our team will contact you within 30 days of receiving this completed form.

    First Name *

    Last Name *

    Email *

    Phone Number *

    Today's Date *

    Address *

    City/State/Zip *

    I Would Like To *

    Briefly Explain The Situation *

    Date Of Occurrence *

    In What Department Did The Situation Occur? *

    Identify Person(s)/Staff Involved *

    Identify Others Who Were Present *

    What Is Your Recommendation To Resolve This Situation? *

    All fields marked with " * " are required.