Ombuds service

Ombudsman service report form

Last name and first name of the person who wishes to make a report *:

Patient's last name and first name (if not directly reporting):

Patient's date of birth:

E-mail address of the person reporting *:

Phone number of the person reporting *:

I'm contacting you because

I want to make a complaint

I want to express a suggestion/appreciation

I want to report a (near) incident

I want to request a copy of my patient file

What specifically do you want to report to the ombudsman service?:

I agree to the processing of my personal data as stated in our privacy policy.

Insturen