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baner 4

Complaint Form

The profile of the complainant:
M/F
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education

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Family relationship with the patient
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Job
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Phone Number
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Mobile Number
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Address*
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Name of the Patient*
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Section
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Medical Records*

Date of Complaints
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Time of the Complaint*
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Date of the Issue
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time*
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shift
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Mobile Number
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Description

Which of the following cases is the issue that you have a complaint:
The person in question, with the names and positions
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Section / unit
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Others to mention
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Explain the details of the complaint:
Please, explain all activities or services that you have received in order to be better analyzed by complaint unit
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Check the subject of complaints:
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Dear client; Please, attach all the copy of contracts, invoices, prescriptions, bills paid, communications related to the subject of your complaint and ... to the original complaint form.
Security Code*
Security Code
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