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Email Forms Manager

If you have an issue or concern you would like University Hospitals Elyria Medical Center to address, please complete the following form and submit it electronically or call the UH Elyria Medical Center 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. * 
Authentication * 

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