REPORT OF UNSATISFACTORY MEDICAL CARE

TO: _________________________________________________________

       _________________________________________________________

      __________________________________________________________

FROM: ______________________________________________________

            _______________________________________________________

           _______________________________________________________

PHYSICIAN NAME____________________________________________

ADDRESS________________________________________________________________

PHONE _____________________FAX_____________________EMAIL___________________________________

PATIENT NAME___________________________________________________________

ADDRESS_______________________________________STATE________ZIP__________________

PHONE_____________________ FAX_____________________ EMAIL___________________________________

DATE OF EVENT______________________

DESCRIPTION OF EVENT

-------------------------------------------------------------------

RESULTS OF EVENT

(1)

(2).

(3)

(4)

-----------------------------------------------------------

REMEDIES REQUESTED:

(1)

(2)

(3)

(4)

----------------------------------------------------

SIGNED___________________________________

DATE________________________