Your data

(the one filing the complaint)

Patient data

(this can also be the patient's representative or next of kin)

Nature of the complaint

The complaint is about: (multiple choices possible)Medical actions of employeeEmployee treatment (= the way the employee talks to or interacts with you)General practice organization (= the way various things are arranged in the practice)Administrative or financial processingSomething else
Description of complaint*

Consent for data use *Yes, I consent to the storage and processing of submitted data

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