Customer Complaint Intake Form

A structured form for capturing customer complaints, order issues, requested resolution, and follow-up details.

Customer Information

• Customer name
  Optional if you prefer to submit anonymously or if your organization already has a case reference.
• Preferred contact email
  Used only for follow-up on this complaint.
• Preferred contact phone
  Optional alternate contact method for follow-up.
• Submit anonymously
  Select this if you do not want to provide identifying information. Anonymous submissions may limit our ability to follow up.

Complaint Details

• Date of complaint
  When the issue occurred or was first noticed.
• Issue category
• Brief summary of the issue
  One short sentence describing the complaint.
• Detailed description
  Include what happened, who was involved, and any relevant context.
• Impact level
  How severely did this issue affect the customer experience?

Order or Service Details

• Is this complaint related to an order?
• Order number
  Enter only the order reference needed to investigate.
• Purchase date
• Service or account reference
  Use this for service, subscription, or account-related complaints.

Requested Resolution

• Requested resolution
• Additional resolution details
  Use this to explain the preferred outcome in more detail, if needed.
• Preferred follow-up method

Attachments and Follow-Up

• Supporting files
  Optional screenshots, receipts, photos, or other relevant documents.
• Additional notes
  Include any other information that may help with review or resolution.
• I consent to being contacted about this complaint
  By submitting contact details, you consent to being contacted for investigation and resolution of this complaint.