Two Rivers Family Health Team is committed to providing excellent service to our patients. If you have a concern with our service, you may submit your care concern using the form below.

Alternatively, if you would simply like to provide feedback about your recent visit, please click on this link to access our Patient Experience Survey.

We listen to your concerns, treat them seriously, and learn from them so that we can continuously improve our service.

Formal procedure to submit a Care Concern:

Complete the “Care Concern” form below and click “Submit”.
Our Clinic Manager will then meet with the management team to review your concern.
If needed, your care concern will be reviewed with other healthcare team members. In some cases, we may ask you to meet with members of our team to review your concern.
If you would like a response from our management team, you will be contacted within four weeks of submitting your care concern. If this timeline cannot be met, a member of our team will let you know when you can expect a response.

Care Concern Form

Date of the Incident(Required)

Time of the incident(Required)

Location/Unit # of the Incident(Required)

Person(s) involved (physician and/or clinic staff)(Required)

Names of people involved (if known)(Required)

Description of incident (what occurred, when, where, who was involved)(Required)

Patient Name(Required)

Please provide the name of the person completing the form, if different than the patient.

Email(Required)

Phone number we may contact you at(Required)

Please select your family doctor:(Required)

Do you give consent to share this care concern with your family doctor/staff member?(Required)

Yes

Would you like a call from Management regarding your experience?(Required)

Yes

I confirm that this is NOT a personal medical question(Required)

Agree

Name

This field is for validation purposes and should be left unchanged.

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Care Concern Form

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