COMPLAINT FORM Complaints and quality
Personal information provided will remain
of services Commissioner
CONFIDENTIAL USER’S (PATIENT’S) IDENTIFICATION Maiden name (as required)
First and last name Complete address E-mail address Telephone
Date of birth Québec health insurance card number
(between 8h30 AM and 4h30 PM)
User’s chart number
USER’S REPRESENTATIVE (IF RELEVANT) First name
Last name
Complete address E-mail address Telephone (between 8h30 AM and 4h30 PM) Relation to user
☐ Legal spouse ☐ Parent ☐ Other (please specify):
☐ Friend
☐ Representative
Please join any relevant documents with present complaint form. Please print your name on copy of each document.
PLEASE CHECK AND STATE LOCATION WHERE EVENT OCCURRED ☐ Hospital
☐ Centre du Florès
☐ CLSC
☐ Centre Le Bouclier
☐ CHSLD
☐ Centre jeunesse des Laurentides
☐ Intermediate resource
☐ La Résidence Lachute
☐ Family home environment resource
☐ Addiction rehabilitation centre
☐ Addiction resource
☐ Community organization
☐ Private senior’s residence
☐ SPU – Ambulances
(VERSO)
Date and time of event Description of event
My request/expectations
User’s signature
Date
User’s representative’s signature (if relevant)
Date
Return form to:
Complaints and quality of services Commissioner By mail: 1000 Labelle street, Saint-Jérôme (Québec) J7Z 5N6 or by fax (confidential ): 450-431-8446 or by e-mail:
[email protected] To reach the Complaints Commissioner: 450-432-8708 Toll free telephone: 1-866-822-0549
« La raison d’être des services est la personne qui les requiert. »
L.R.Q., c. S-4.2.art.3 Vd‐ANG 2015‐01‐04
