Complaint formComplaint form"*" indicates required fieldsDetails of the reporterGender Male FemalInitials*PrefixesLast name*E-mail* Phone*Date of birth* DD slash MM slash YYYY Adress*Postal Code*Location*CountryComplaint on behalf of someone elseAre you submitting the complaint on behalf of someone else? No YesWhat is your relationship to the patient?*Parent or caregiverChild ofFamilyOtherwiseVul hieronder de gegevens van de patiënt inGender* Male FemaleInitials*PrefixesLast name*E-mail* Phone*Date of birth* DD slash MM slash YYYY Street + house number*Postal code*Location*CountryDescription of complaintDate of the event DD slash MM slash YYYY Description of the complaint/problemYour report concernsthe organisationthe triage nurse, telephone operator, assistantthe driverthe doctorWhat do you think is the cause?waiting timesincorrect assessment of the urgent nature of my questionwrong treatmentincompetent care providertreatmentotherwise, namelyDescribe the cause of the complaint/problemCould the incident have been prevented? No YesDo you have any recommendations to prevent such an occurrence in the future?Does the patient or representative give permission to view the file?*Inspection is necessary so that the complaints officer can handle your complaint carefully Yes NoCAPTCHA
