178 Columbia St, Chester, SC 29706
803-209-8667
info@larcareservices.com
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VA SamariCare - Rights to Complain
I acknowledge that I have the right to complain if I am unhappy about any of the services provided. I can reach LarCare representatives at 803-209-0956 or 803-209-8667. I will exercise my right to cancel if needed.
Patient First Name *
Patient Last Name *
Patient Date-Time
Patient Signature — type your full legal name to sign *
Nurse First Name *
Nurse Last Name *
Nurse Signature — type your full legal name to sign
LarCare Witness First Name *
LarCare Witness Last Name *
Witness Signature — type your full legal name to sign
Signature Date-Time
I confirm the above signatures are authentic and electronically executed *
Submit