Complaint Form – CISSS de la Montérégie-Centre

The information submitted is CONFIDENTIAL.

In order to examine your request, the team of the Complaints and Service Quality Commissioner may access personal information. It could also exchange, in a confidential manner, information concerning your request, with the people or authorities concerned.

All personal information contained in the file created by the office of the commissioner is only accessible to persons duly authorized to consult it, for whom knowledge of this information is necessary to the exercise of their functions.

STEP 1 OF 4 - IDENTIFICATION OF THE USER

USER'S FIRST NAME

USER'S LAST NAME

ADDRESS (NUMBER, STREET, APPARTMENT)

CITY

POSTAL CODE

PHONE (HOME)

PHONE (OTHER)

LOCATION CONCERNED (HOSPITAL, CLSC, CHSLD, OTHERS)

Location Concerned (Hôpital Charles-Le Moyne, Hôpital du Haut-Richelieu, CLSC (please, specify the site), CHSLD (please, specifiy the site), others.

ROOM NUMBER

USER'S RECORD NUMBER

DATE OF BIRTH

STEP 2 OF 4 - IDENTIFICATION OF THE LEGAL REPRESENTATIVE (IF APPLICABLE)

Complete this section only if the complaint is not lodged by the user.

LEGAL REPRESENTATIVE'S FIRST NAME

LEGAL REPRESENTATIVE'S LAST NAME

ADDRESS (NUMBER, STREET, APPARTMENT)

CITY

POSTAL CODE

PHONE (HOME)

PHONE (OTHER)

RELATIONSHIP TO THE USER

STEP 3 OF 4 - THE COMPLAINT – STATEMENT OF THE FACTS

DESCRIPTION - THE COMPLAINT

STEP 4 OF 4 - USER’S EXPECTATIONS

DESCRIPTION - EXPECTATIONS

YOU CAN ATTACH DOCUMENTS TO YOUR COMPLAINT.

Maximum 5 files.
20 MB limit.
Allowed types: gif, jpg, png, bmp, eps, tif, txt, rtf, pdf, doc, docx, ppt, pptx, xls, xlsx, svg.

I WOULD LIKE TO RECEIVE THE CONCLUSIONS BY E-MAIL

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