Complaint Form
Please fill in your details below.
If you prefer to remain anonymous, you may skip filling in your details.
Name
First name
Last name
Date of Birth
-
Dag
-
Maand
Jaar
Date of birth
E-mail
example@example.com
Mobile phone number
Enter a valid phone number
Format: 0000000000.
Details complaint
When did the issue occur?
*
-
Dag
-
Maand
Jaar
Date
Where did the issue occur?
*
In a consult room
In the waitingroom
In the hallway
Outside of the building/practice
In multiple places
Online/on the phone
Who was involved?
*
A doctor
Dr. F Ogbuli
Another 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?
*
Yes
No
Submit
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