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Section 1. Person Filing Out the Complaint Form Information
Section 2. Facility Information
Section 3. Patient Information
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Section 4. Complaint Information (20000 Characters Max)

Names of any other person(s) or witness(es) involved in this complaint
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Person 2 / Witness 2

Section 5. Reporting of Complaint
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Upon Clicking Continue to Review and Submit button you will be able to upload documents/pictures pertaining to this complaint