Patient form - Request for mediation

Are you the patient involved?*

YES

NO

SURNAME*

First name*

Date of birth

Address

Postcode

Coty

Country

Telephone number*

E-mail address*

On which hospital site did the incident take place?*

Delta

St-Anne St-Remi

Cavell

Basilique

Europe-Lambermont

Park Leopold

CityClinic Louise

Braine-l'Alleud

Describe the reason for your dissatisfaction*

Send