Compliance | Square Care Health

Incident Form

CALL 911 IF THIS IS AN EMERGENCY OR AN IMMEDIATE THREAT TO LIFE OR PROPERTY.

Report an Issue

Are you an employee of Square Care Medical Group, LLP? *

Yes

No

Do you wish to remain ANONYMOUS for this report?*

Yes

No

Your Name*

Your Phone Number*

Your E-Mail Address*

Best time to contact you*

Relationship to Patient

If other, please state relationship

Where did incident or violation occur? Scroll options to choose a division*

Please provide all details regarding the alleged violation, including the locations of witnesses and any other information that could be valuable in the evaluation and ultimate resolution of this situation.*

Please provide the specific or approximate time this incident occurred:*

If you have a document or file that supports your report, you can attach it here.