La Clínica del Pueblo

Date of visit*

Date

Service(s) received (if applicable)

Facility location*

Washington, DCHyattsville, MDLa CasaTelehealth

Name of La Clínica Employee(s) Involved (if applicable)

Nature of feedback

Your feedback*

How would you like to see your feedback addressed?

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

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Email

example@example.com

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.

Please verify that you are human*