Patient Grievance Form

Patient Grievance Forms are collect by GITA’s volunteer patient advocates. Filing this report and having a patient advocate intervene on your behalf is one of your rights as an ibogaine patient. Please be as thorough as possible, and one of our volunteer patient advocate will contact you shortly.

Personal Information
Name*
Prénom Nom
Email*
Phone*
Address
Adresse Ville État / Province / Région ZIP / Code postal Pays
- I am filling out this form on behalf of someone else who received treatment.
Name of Patient*
Prénom Nom
Your relationship to the Patient*
- I wish to remain anonymous.
By opting to remain anonymous, your name and personal information that you provided above will be kept confidential, and will never be shared in a way that may notify the provider of your identity. Please be aware that this may, in some cases, limit our ability to moderate, in which case we will notify you. By selecting the option below this disclosure will always remain your choice.*
- I understand, please maintain my anonymity.
Report Details
Ibogaine Provider Name*
Prénom Nom
Clinic or Organization
Clinic/Organization Address
Adresse Ville État / Province / Région ZIP / Code postal Pays
Ibogaine Provider Email
Ibogaine Provider Phone
Clinic/Organization URL
Please describe the situation in detail*
Please include any relevant dates.
What outcome would you like to see (if any) through the mediation process?
Email
This field is for validation purposes and should be left unchanged.

Personal Information

Report Details

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Patient Grievance Form

Personal Information

Report Details

À Propos

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