If you have a complaint or grievance about our services, please let us know by filing out the form below.

Instructions: Please provide detailed information about the issue or complaint. This form will help ensure that the matter is investigated in accordance with Hemophilia of Georgia's compliance policies. All fields must be filled out as completely as possible. If you prefer anonymity, please indicate so, but providing contact details may help in resolving the matter.

1.	Date of Submission *
2.	First name *
3.	Last Name *
4.	Email address *
5.	Phone Number *
6.	Describe the Issue: [Provide a detailed description of the complaint or issue.] *
7.	Date/Time the Incident Occurred: *
8.  Have you reported this issue before? *      Yes  2 No
9.	If yes, what was the outcome of the previous report?
10.	Is there any additional information you believe is important for us to know?
11.	What outcome would you like to see as a result of this grievance? *
12.	Signature and Consent *	(?)
	By signing this form, I acknowledge that the information provided is true to the best of my knowledge and understand that it will be used to investigate the grievance in accordance with company policies.