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Food Complaint Form

  1. Contact Information
  2. Food Establishment Information
  3. What foods were eaten (including appetizers, entrees, drinks, and desserts)?

  4. Complaint Information
  5. Please describe your complaint about the food service establishment.

  6. Any Related Illness?

    Did you or anyone in your party have any illness that you feel is related to your experience with the food service establishment?

  7. Date of Symptoms
  8. Medical Attention

    Did you seek medical attention regarding your illness?

  9. Leave This Blank:

  10. This field is not part of the form submission.