Patient Complaint Form
All patient concerns are strictly confidential.
To fill out or print out word document please click on complaint form and email to This email address is being protected from spambots. You need JavaScript enabled to view it.
Or Mail:
Attention: Michelle Bousquet - Executive Director, CFO
Clinique St-Boniface Clinic
343 Tache Ave
Wpg MB, R2H 2A5
Form when printed out will look like below:
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Date of incident: |
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Your Name: |
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Physician you were seeing in clinic today or reason for visit: |
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Describe the concern in your own words: |
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Staff Completion Only: |
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Investigation, Follow up, and resolution: |
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Completion Date: Sign off: |
