Satisfaction, comment and suggestion form - CISSS de la Montérégie-Centre

Your personal information could be used to respond to your comment/suggestion. If so, it will only be provided to those concerned.

STEP 1 OF 3 – IDENTIFICATION OF THE UNIT OR DEPARTMENT CONCERNED

Date

UNIT/DEPARTMENT

LOCATION

STEP 2 OF 3 – IDENTIFICATION OF THE USER OR HIS/HER REPRESENTATIVE

To be completed only if the complaint is not submitted by the user.

YOU ARE?

USER

REPRESENTATIVE

LAST NAME

FIRST NAME

Adress

Phone (Home)

RELATIONSHIP TO THE USER (IF APPLICABLE)

STEP 3 OF 3 – COMMENT/SUGGESTION

YOUR MESSAGE

ADD DOCUMENT/S IF NECESSARY

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