• You may submit this anonymously or fill in your contact information if you wish to be contacted:

  • By completing this form, you acknowledge that you may be sharing private information.

    La Clínica does not include these submissions in your chart or any patient records we

    maintain for you. If you need to speak to the healthcare team about a health issue,

    reach out via the Healow patient portal or call (202) 462-4788.

  • Should be Empty: