Link here to fill out the report
card
in your browser.*
Once you
have filled it out in the browser,
you will need to print it, then mail
it. |
Link here to a pdf version.
You can print the report card first.
You'll fill it out by hand, then
mail it.
You will need
the PDF reader to open this file.
If you have trouble opening the
file,
link here. |
Has your doctor done something
dangerous -- an error or
misdiagnosis?
Consider
sending a copy
to your local medical society, or
even your state’s
medical board.
Find links to state boards.
*We cannot email this
report card to your doctor for you.
Why not? Two reasons.
First, if we accepted this information from
you digitally, we would be violating your
privacy, which is against federal law.
Secondly, most doctors do not publicize
their email addresses, so we would have no
way to email that information to the right
person.
DiagKNOWsis Privacy Statement:
Information you supply on this form will not
be transferred electronically; therefore we
have no way of retaining any information you
input. All your information will remain
private and secure since it cannot be
collected.
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