UZ Brussel: Complaint form

First name*:

Last name*:

Street*:

Number*:

City*:

Zip code*:

Date of birth*:

Telephone/mobile number*:

Email:

Care unit/specialist of the patient*:

Complaint concerns the following care unit/consultation*:

Date of incident*:

The complaint concerns (please check the box which describes the best the nature of your complaint):

a treatment

the medical care

a permission of treatment

communication about the treatment

the (not) received information

consultation of the medical file*

the organisation

other

(*) Please contact your general practitioner first. If you still want to consult your medical file, please contact your specialist or the ombudsperson at UZ Brussel, and provide your full name, complete adress, date of birth and a copy of your ID card.

Describe the complaint*:

In case you are not the patient himself/herself

Full name:

Street:

Number:

City:

Zip code:

Telephone/mobile number:

Ombudsperson

Complaint form