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Atención al paciente
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Sobre nosotros
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Formulario De Reclamación Por Daños Materiales
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Contáctanos
Formulario De Felicitaciones
Formulario De Reclamación
Cuestionario Sobre La Mejora Del Servicio
Formulario De Reclamación Por Daños Materiales
Formulario De Reclamación Por Daños Materiales
Formulario de reclamación por daños materiales
Nombre de pila
*
Apellido
*
Dirección de correo electrónico
*
Número de teléfono
*
Fecha de nacimiento
*
Dirección particular
*
Número de teléfono del paciente
Nombre de la persona de contacto
¿Qué denunciaste?
*
Daño
artículo extraviado
What is damaged or missing/lost? (please keep damaged items and show them on request)
*
Did another party pay for the item?
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Yes
No
Do you have a proof of purchase receipt?
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Yes
No
Has the damaged item been sent to the laundry/repair?
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Yes
No
Where did you purchase the item?
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What was the purchase price/value?
*
In case of damage, do you have a money transfer receipt?
*
Yes
No
In which department at the hospital did the damage/loss occur?
*
Where were you located at the time of the damage/loss?
*
How did the damage/loss occur?
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In case of loss, was there a possibility to place your belongings in safekeeping?
*
Yes
No
Do you consider hospital staff or a fellow patient responsible for the damage/loss?
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Yes
No
Can there be witnesses to this incident?
Has the damage/loss been reported to a supervisor, management, or an employee?
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Yes
No
Has a report been filed with the police?
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Yes
No
If you purchased medical equipment, was its packaging placed in safekeeping?
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Yes
No
Do you consent for SMGH to access relevant records for handling this incident?
*
Yes
No
Today's Date
*
What type of claim do you seek (repair, replacement, reimbursement)?
*
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