Gastroenterology, Ltd. of Virginia Beach Cancer Prevention & Endoscopy Center

Our Mission

to provide high quality digestive and endoscopic health care in a compassionate, comprehensive, cost effective manner while assuring the highest level of respect and integrity for the patient.

Patient Name*
Address*
Telephone #*
Date of Birth*

Name of Person Initiating Complaint*
Address
Telephone # *
Relationship to Patient*
Nature of Complaint
Time & Date of Incident
Names of Staff Involved (if known)
In your own words please tell us why you are not happy with the care or service you received:
As a result of your complaint, what would you like to see happen?

I understand that staff investigating this complaint may need to see and review health records, but that all information will be kept confidential. I further understand that this complaint/grievance will in no way affect any care provided.

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GASTROENTEROLOGY, LTD PATIENTS