Complaint's registration Form

Yazd, Mahdieh Square, beginning of Imam Jafar Sadegh Blvd.

We turn every complaint into an opportunity to improve patient treatment.

Tracking & Basic Information

Tracking Code

Patient's Full Name

Complaint's Occurrence Date & Time

Which department of the hospital are you complaining about?

Doctor's Name

File Number

Reception's Date

Discharge's Date

Complaint's Cause

Name and Post of the person you are complaining about

Complainer's Education

Complainer's Occupation

Address

Phone Number

Who is the complainer

Patient

Accompanying the patient

Other

Full Name & Signature

Description of the Complaint

Full description of the complaint (Who? When? Where? Who involved in it?)

Follow up information

عزيزي مقدم الطلب: احتفظ بهذا القسم معك وتابع شكواك بعد أسبوع من خلال شفرة التتبع.

درخواست کننده محترم: این قسمت را جدا و نزد خود نگه دارید و جهت پیگیری شکایت خود یک هفته بعد از طریق کد رهگیری اقدام نمائید

Dear applicant: Keep this section in your memory and follow up on your complaint a week later through tracking code.

Code Tracking

Date and time of complaint

SMS Number

Phone number: 035-33182261 | Internal number: 261