Confidential Reporting

This form is a secure method to privately report any concerns or issues that you may have seen or experienced at one of our clinical sites. All reports will be reviewed by our Ethics and Compliance Officer.

Your Name (This is optional)
First Name:

Last Name:

Your Phone Number: (This is optional)

Your Email: (This is optional)

Are you a patient or an employee?: (This is optional)
PatientFamily Member or Friend of PatientEmployeeFormer Employee

Who are you reporting? *(Required)
Reception StaffBilling or Eligibility StaffNursing StaffDoctor, Nurse Practitioner or Physician AssistantDentistDental Hygienist or AssistantLaboratoryPharmacyCleaning Crew, Maintenance Crew, Etc.Security OfficerManagementBoard MemberOther

Select Location: *(Required)
---De LeonBrownwood MedicalBrownwood DentalStephenville

Date the problem occurred: *(Required)

Time the problem occurred: (This is optional)

Subject: *(Required)

Please describe your concern. Please be as detailed as possible. *(Required)