Complaint Form

The profile of the complainant:

M/F

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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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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*

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