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Email Forms Manager
If you have an issue or concern you would like EMH Regional Healthcare System to address, please complete the following form and submit it electronically or call the EMH Patient Complaint Response Line at (440) 329-7391.
* Indicates required information
Patient Information 
First Name * 
Last Name * 
Street Address 1 * 
Street Address 2 
City * 
State * 
Zip * 
Email Address 
Home Phone Number 
Work Phone 
Birth Date *    (mm/dd/yyyy)
Person completing form if different than patient. 
Your Concern/Issue 
Date of Visit *    (mm/dd/yyyy)
Facility * 

If Other, please specify:
Briefly explain your concern. * 
Department 
Person(s) Involved (if known) 
How would you like it resolved? * 
Click here to authorize investigation. * 
 


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EMH Regional Healthcare System, 630 East River St., Elyria, OH 44035, (440) 329-7500