FORMS / COMPLAINT FORM

Complaint form.

We are sorry that your visit did not go as you had hoped. We aim to be transparent and customer-friendly and to resolve your complaint as soon as possible. Your complaint will be handled by the management of your clinic, who will contact you by phone or in writing about the progress. We comply with applicable privacy legislation when processing your complaint.

01 / REPORTER CONTACT DETAILS

How can we reach you?

Are you the patient/client? * First Name * Last Name *

Salutation *

Mr. Ms. Other

Phone number * Email address

02 / GENERAL INFORMATION ABOUT THE COMPLAINT

When and where?

Date the complaint arose * Clinic / practice *

03 / DESCRIPTION OF THE COMPLAINT

What happened?

Description of the complaint * Attachment(s)

Choose files No file chosen

Optional. Up to 5 files; JPG, PNG, WEBP, PDF, DOC/DOCX; max 5 MB each.

Required fields are marked with *. Your details are kept confidential and used only to handle your complaint.