Fort Wayne Allen County Department of Health

Complaint Form

Please select a complaint type, above.

Hotel / Motel Complaint:

Location of Complaint:
(ie. Room Number) List the Complaint:
Please include dates, times, locations, names of those involved, and any other important details and send any accompanying documentation to info@allencountyhealth.com Did You Contact Management?

Yes

If So, List the Name of Contact:

Food Complaint:

Nature of Complaint
For multiple choices, use the CTRL key

* If complaint is of illness, be sure to submit name and daytime phone number. A department representative will contact you for more information. Please do not submit any medical information.

List the Complaint:
Please include dates, times, locations, names of those involved, and any other important details and send any accompanying documentation to info@allencountyhealth.com Was the food consumed in the establishment or carried out?

In the establishment

Carried Out

What food was involved?:

Tattoo Complaint:

Nature of Complaint
For multiple choices, use the CTRL key

* If complaint is of illness, be sure to submit name and daytime phone number. A department representative will contact you for more information. Please do not submit any medical information.

List the Complaint:
Please include dates, times, locations, names of those involved, and any other important details and send any accompanying documentation to info@allencountyhealth.com

Your Contact Information (optional)

If complaint is of illness, be sure to submit your name and daytime phone number so that a department representative can contact you for more information.

Name: Daytime Phone Number: Address:

Allen County Health Dept Complaint Form