Issues or Concerns Form
Issues or Concerns Form
Please complete the following form if you have any issues or concerns regarding your visit.
Date of your visit
Date of your visit
*
/
MM
/
DD
YYYY
Time
Time
*
:
HH
MM
AM
PM
AM/PM
Name
Name
*
First
Last
Phone
Phone
*
-
###
-
###
####
Panther ID
*
Maximum of
7
digits allowed.
Currently Entered:
0
digits.
FIU Email
*
Please select one or more options below that best fits your concern or inquiry:
*
Please select one or more options below that best fits your concern or inquiry:
Missed Appointment Fee
Charges/Fees
Provider Complaint
General Complaint
Other
Please write a brief statement regarding your concern or inquiry:
*