Fillable SITE : HGM/MGH (General) GLEN PDIATRIQUE/PEDIATRICS GLEN ADULTE/ADULT (McGill University Health Centre)

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SITE : HGM/MGH (General) GLEN PDIATRIQUE/PEDIATRICS GLEN ADULTE/ADULT (McGill University Health Centre)

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Country of origin: CANADA
File type: PDF

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Date : __________________________________
SITE : HGM/MGH (General) GLEN PÉDIATRIQUE/PEDIATRICS GLEN ADULTE/ADULT
LACHINE HNM/MNH (Neuro)
IDENTIFICATION
PATIENT
REPRÉSENTANT / REPRESENTATIVE
NOM / NAME :
NOM / NAME :
ADRESSE :
ADRESSE :
TÉLÉPHONE – MAISON / HOME :
TÉLÉPHONE - CELL :
TÉLÉPHONE – MAISON / HOME :
TÉLÉPHONE - CELL :
# DOSSIER / CHART # :
D.D.N. / D.O.B. :
LIEN / RELATIONSHIP :
PLAINTE / COMPLAINT
Précisez : le lieu (urgence, clinique, etc.), la date et l’heure/ Tell us: the place (emergency, clinic, etc.), the
date and time
LANGUE/LANGUAGE : Français / French Anglais / English
PLAINTE / COMPLAINT (suite / cont’d)
RÉSULTATS ATTENDUS / EXPECTED OUTCOME
Je consens à ce qu’un membre du bureau de la Commissaire aux plaintes examine mon dossier et
que l’information pertinente soit transmise aux personnes concernées et consultées/ I consent to the
examination of my file by a member of the Ombudsman’s office and to the transmission of the
pertinent information to the concerned and consulted persons
Signature du plaignant / Complainant’s signature : _______________________________
Vous pouvez envoyer ce formulaire par télécopieur au numéro suivant \ You may send this for by
fax at the following number : 514-934-8200
Vous pouvez également envoyer ce formulaire par courriel à l’adresse suivante \ You may also
send this form by email at this address : ombudsman@muhc.mcgill.ca
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SITE : HGMMGH (General) GLEN PDIATRIQUEPEDIATRICS GLEN ADULTEADULT (McGill University Health Centre)

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Completed 16 September 2021

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