HofpoortInfo - Zuwe Zorg intranet
HofpoortInfo - Zuwe Zorg intranet
HofpoortInfo - Zuwe Zorg intranet
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32<br />
#<br />
Enquêteformulier<br />
Op dit formulier kunt u uw op- en aanmerkingen over uw behandeling of uw<br />
verblijf kenbaar maken.<br />
Zend het formulier in een ongefrankeerde envelop aan:<br />
Klachtenfunctionaris, <strong>Zuwe</strong> Hofpoort Ziekenhuis, Antwoordnummer 2113,<br />
3440 VB Woerden.<br />
De behandeling/het verblijf in het <strong>Zuwe</strong> Hofpoort Ziekenhuis heb ik als volgt ervaren:<br />
...............................................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
Mijn suggesties, op- of aanmerkingen zijn:<br />
...............................................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
Ik ben op de polikliniek geweest van:............................................................................................................................... (specialisme)<br />
op: ................................................................................................................................................................................................................................. (datum)<br />
Ik ben opgenomen geweest op afdeling: ........................................................................................................................................................<br />
in de periode van:.......................................................................................................... tot ...............................................................................................<br />
Dit zijn mijn adresgegevens:<br />
Naam/voorletters: ..................................................................................................................................................................................................................<br />
man/vrouw<br />
Adres: ..............................................................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
Postcode/woonplaats: ......................................................................................................................................................................................................<br />
...............................................................................................................................................................................................................................................................<br />
Telefoonnummer:....................................................................................................................................................................................................................<br />
E-mail: ..............................................................................................................................................................................................................................................<br />
n Ja, ik wil graag antwoord ontvangen
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