You can also use the on-lineform on www.amsterdamumc.nl/nl/vragen-en-klachten.htm .

Personal data

Name

Date of birth

M/F/X

Address

Postal Code, City

Phonenumber (office hours)

Patient ID (MDN)

E-mail

Does your complaint/suggestion concern: □ location AMC □ location VUmc

□ clinic/ward □ an out-patient clinic □ other

Please specify/describe which one:

Are you the patient involved? □ yes

□ no, your name:_________________________________

relationship to the patient: ______________________

telephone:_____________________________________

□ not applicable

Following your report, an employee of the complaints department will contact you.

Please indicate a convenient time (business hours):

In order to handle your complaint we may need to access your medical record. Therefore we need your informed consent. If you do not want that, please tick this box: □

Please descibe your complaint/suggestion:

You can also use the other side of this form

Signature:___________________________________________ Date: ________________

You can either drop of this form or submit it by post to the following address:

Amsterdam UMC location AMC: afdeling Patiëntenservice Zorgsupport, A0-404

location VUmc: afdeling Patientenservice Zorgsupport, PK 0 hal 08

Post: Amsterdam UMC, t.a.v. klachtenfunctionaris/complaintsofficer

Postbus 22660

1100 DD Amsterdam

E-mail: klachten@amsterdamumc.nl

­­­­________________________________________________________________________________

Describe your complaint/suggestion – continue:

_____________________________________________________________________________________

Registration by Patient Information Department

Received by: ______________________________ Date: _____________________________