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SGE Complaintsform
Last name
*
Initials
*
Gender
*
Male
Female
Date of birth
*
dd/mm/yyyy
My complaint regards
*
the health center
a healthcare provider
financial administration
other, i.e.
other, i.e.
My complaint:
How would you like us to handle your complaint?
*
I would just like to register my complaint and have it forwarded to the manager responsible (you will not be informed of the results, nor will you be contacted).
I would like to be contacted
Please contact me
by email
by telephone
E-mail address
*
Telephone number
*
Thank you for submitting your complaint.
mailadres verantwoordelijk leidinggevende
Status :
Open
In behandeling bij verantwoordelijk leidinggevende
Geen klacht
Gereed en naar tevredenheid afgehandeld
Geëscaleerd naar klachtencommissie SGE
*
=
Input is required