Complaint form

Name: *
Email address: *
Phone number: *
Date of birth: *
Gender: *
Address: *
Postal code + city: *
Patient Number:
I am submitting a complaint as: *
Who or which department is your complaint related to?: *
What date / period is your complaint related to?: *
Complaint Description: *
Have you already discussed the complaint with the affected employee (s)?: *
If so, with what result?:
What do you want to achieve by reporting your complaint?:
When submitting a complaint, do you authorize the complaints mediator to look at your file? Do not want this? Please state clearly here.:
 
Verification: *