Queen Beatrix rd #25, St. Eustatius
+599-318-2211
info@sehcf.org
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Out Patient Survey
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DEPARTMENTS
EVENTS
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CONTACT
– Out Patient Survey
Complaint Form SEHCF
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Complaint Form SEHCF
Complaint Form SEHCF
*Vereist
Name of Complainant
(optional)
Jouw antwoord
Age
*
please indicate your age category
Kiezen
17 and under
18 - 29
30 - 39
40 - 49
50 - 59
60 and up
Gender
*
Kiezen
Male
Female
Your complaint involves which department?
*
more than one department possible
Front desk
Poli-Clinic
Doctor
Midwife
Laboratorium
X-ray
District Nursing
In-Patient Ward / Staff
Emergency Room
Ambulance / Staff
Domestic Staff
Kitchen
Maintenance
Financial Department
Anders:
Verplicht
Please select a suitable category of complaint
Unsatisfactory treatment
Long waiting to be attended
Unsatisfactory hospital hygiene condition
long wait for refferal
Anders:
Please write down a detailed complaint
Jouw antwoord
Describe what measures can be taken to prevent a repeat of this incident
Jouw antwoord
Does complainant wish to be contacted
Kiezen
Yes
No
Telephone number
Jouw antwoord
Email Address
please fill in your email address for response
Jouw antwoord
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