Personal Information

*Your Name:
Patient's Name: (if different)
Your Address:
City:
State:
Zip:
*Patient's Birthdate:
*Phone:
*E-mail:

*Location of Service:

<-- Select a Location --> Wheaton Franciscan Healthcare All Saints Wheaton Franciscan Healthcare Brown Deer Wheaton Franciscan Healthcare Elmbrook Memorial Wheaton Franciscan Healthcare Franklin Wheaton Franciscan Healthcare Glendale Wheaton Franciscan Healthcare St. Francis Wheaton Franciscan St. Joseph Wheaton Franciscan Wisconsin Heart Hospital Wheaton Franciscan Healthcare Wauwatosa Wheaton Franciscan Healthcare WFMG Wheaton Franciscan Healthcare Home Health and Hospice Other

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If you have an experience that you want to tell us about, please fill out the form above or contact the location where you received your care using the numbers below:

• All Saints Prideline at (262) 687-2131
• St. Francis Patient Advocate at (414) 647-7145
• Franklin Patient Advocate at (414) 325-4532
• Wheaton Franciscan Medical Group (414) 465-3503
• St. Joseph, Elmbrook Memorial, The WI Heart Hospital, Wauwatosa, Brown Deer, and Glendale Customer Care Line at (414) 447-7433. For a direct line contact the Patient Advocate at (414) 447-2842

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You also have the right to file a complaint with:

State of Wisconsin Department of Health and Family Services Office of Quality Assurance P.O.Box 1969 Madison, WI 53701-2969 (608)243-2024

Joint Commission on Accreditation of Healthcare Organizations Office of Quality Monitoring One Renaissance Boulevard Oakbrook Terrace, IL 60181 (800) 994-6610 http://www.jointcommission.org/

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