Patient Complaint Form

Please Note

The Commission is required to provide your name and description of your complaint to
the healthcare establishment against which you are making your complaint.

By filing this complaint you are authorizing the Commission to have complete access to
all the record relevant to the matter.

Instructions

Please fill out the form completely. Also submit a duly notarized affidavit, according to
sample format, attached to this Complaint Form.

If you need assistance to fill in the form or require any information, please call the PHC
Helpline 0800 00742 (toll free).

Details of the Complainant

Mr. Mrs. Ms

Name________________ ___________________ _____________________

(First) (Middle) (Last)

CNIC No: ___________________ Address:___________________________________

______________________________________________________________________

District::_________________ Tehsil: ________________ Postal Code: _____________

Mobile No: ____________________ Telephone No: ____________________________

Fax: _________________________ Email Address: ____________________________

Are you the patient/client who received health service/treatment?

Yes
No

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 Patient Complaint Form

If not, please mention:

What is your relationship with the patient/client?

Next of kin (for example parent, spouse, sister etc.)_________________

Other (please specify) _______________________________________

Is the patient/client alive?

Yes
No

Is the patient/client disabled or needs assistance?

Yes
No

Details of the Patient/ Client who received heath service

Mr. Mrs. . Ms.

Name________________ ___________________ _____________________

(First) (Middle) (Last)

CNIC No: ___________________ Address___________________________________

______________________________________________________________________

District: _________________ Tehsil: ________________ Postal Code: _____________

Mobile No: ____________________ Telephone No: ____________________________

Fax: _________________________ Email Address: ____________________________

Details of the Healthcare Establishment (HCE)

Name of HCE/place where health service was provided: _________________________

______________________________________________________________________

Address_______________________________________________________________

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 Patient Complaint Form

Telephone: ___________________ Fax: ________________________

Email Address: _____________________________

Name of the Administrator/ In-charge/ of the HCE: ________________________

Mobile: __________________________

Names/Designations of the persons you want to complain about:

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Write your Complaint

Use the space below to write your complaint. Please include persons who were
involved, what happened and when. Please attach a separate page if you want to give
us more details.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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 Patient Complaint Form

What is the nature of the harm done to the patient/client as a result of the treatment?

Death
Unconsciousness
Extreme physical pain,
Protracted and obvious disfigurement, or
Impairment or temporary loss of the function of a bodily member, organ, or
mental faculty.
Bodily injury which involves a substantial risk of death,
Permanent loss of bodily function
Other

When did you come to know about the problem which resulted into your grievance?
Please mention the date.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

What is your specific request to the Commission?

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Did you complain to the In-charge of the HCE about this matter?

Yes
No

If yes, what was the result? Please attach relevant documents if any.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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 Patient Complaint Form

Did you make a complaint to any other organization about the same matter?

Yes
No

If yes, mention the date on which you made that complaint and its result? Please attach
relevant documents if any.

______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

Attach copies of these documents with your complaint

Affidavit
Copy of your CNIC or any other document depicting your identity;
Copy of CNIC of patient/client
Medical records; if any
Receipts; if any
Correspondence with the concerned healthcare establishment, healthcare
service provider or other authorities, if any; and
Other relevant documents in support of the complaint.

Please send your complaint and supporting material to this address

Punjab Healthcare Commission

Office #1&2, 4th Floor, Shaheen Complex
38, Abbot Road Lahore
Fax: 042-36376370
Email: complaints@phc.org.pk

Privacy Statement
The Commission will not disclose any information provided by you other than in carrying
out its functions under the Punjab Healthcare Commission Act, 2010.

Sign here Thumb impression

Date

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 Sample Format for Affidavit
(Produce the following content on a duly notarized stamp paper)

AFFIDAVIT OF ____________________
S/o or as the case may be
R/o

I solemnly affirm and declare as hereunder:

1. Mention the contents of your complaint

2. That the allegations contained in the complaint are true and

correct to the best of my knowledge and belief.

3. That no suit, appeal, or any other proceedings in connection with the

subject matter of the complaint are pending before any court of
competent jurisdiction;

4. That no allegation contained in the complaint is without reasonable

and justifiable ground(s) and that it is not being made simply
with an intention to harass, defame, embarrass and/or to
pressurize the party complained against.

5. That I fully understand that in case my complaint is proved to be false,

then I shall be liable to pay fine, which may extend to Rupees Two
Hundred Thousand.

6. That I undertake to keep the Commission informed of my address and

contact details and I further undertake that I shall regularly attend the
hearings on the dates fixed by the Commission and fully understand that
if I fail to attend the same for no sufficient
reason, or wilfully delay the proceedings of the Commission in its
opinion, then I shall be liable to pay the costs as awarded by the
Commission and that the Commission shall decide the complaint as per
thegoverning law.
7. That a complaint was earlier made to the Healthcare Establishment,
the same was not redressed by it (or as the case may be give details; If
no complaint was made then it must be so mentioned, attach record
relating to the said complaint, if any).

8. That I have not filed a complaint on the same subject matter

before the Commission nor the same matter is already pending
before the Commission and further that the subject matter has
not already been decided by any forum.

9. That I am fully competent to apply for and obtain the autopsy Report for
the purposes of determining the real cause of death of Mr. ____________
(deceased) and that I undertake that I am ready and willing to get the
same through the process of exhumation and post-mortem and provide
the same to the Commission at the earliest. (Only applicable in cases
where the patient has died and there is no autopsy report- In case the
Complainant does not wish to obtain the said report then he shall state so
in the affidavit)

DEPONENT

Verification: -

Verified on oath at _____________ on this ___ day of ____ 2013 that the
contents of the above Para No. ____ to Para No. ____ are true and correct to the
best of my knowledge and belief and those of Para No. ____ to _____ are
correct as per the information provided to me and that nothing has been
concealed therefrom.

DEPONENT

OR IF THE INFOMRATION IS BASED ON SELF KNOWLEDGE AND

BELIEF THEN: -

DEPONENT
Verification:-
Verified on oath at _____________ on this ___ day of ____ 2013 that the
contents of the above affidavit are true and correct to the best of my knowledge
belief and that nothing has been concealed therefrom.

DEPONENT