大象传媒
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Department of Pediatrics
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NC Child Medical Evaluation Program
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Contact CMEP
Contact CMEP
Do Not Submit Patient Information on this Form
To report a concern regarding a service
Name of Person with Concern
First
Last
Role in the Service that was provided
Patient
Parent/Guardian of Patient
Child Welfare
Community Member/Other
CMEP Service
Child Medical Evaluation (CME)
Clinical Assessment of Protective Parenting (CAPP)
Regional Abuse and Medical Specialists (RAMS)
Child and Family Evaluation (CFE)
Please describe your concern, without using patient information.
Do you want to be contacted by CMEP regarding your concern?
Yes
No
Your Contact Information
Full Name
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Last
Email
Phone
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