Klachtenformulier

Complaint Form
Please fill in your details below.

If you prefer to remain anonymous, you may skip filling in your details.
Name

First nameLast name
Date of Birth

DagMaandJaar
Date of birth
E-mail
example@example.com
Mobile phone number
Enter a valid phone number
Details complaint
When did the issue occur?*

DagMaandJaar
Date
Where did the issue occur?*

In a consult roomIn the waitingroomIn the hallwayOutside of the building/practiceIn multiple placesOnline/on the phone
Who was involved?*

A doctorDr. F OgbuliAnother health care provider (please fill in the name and function of the person if you know it)Generally, the practice
Name and function of the health care provider
Describe the issue and your expectation from us as detailed as possible*
May we contact you for more information or discussion about the issue?*

YesNo
Should be Empty:

Complaint Form