User recording of expression

Article R. 1112-91. Public health code

Every user of a health establishment must be able to express his grievances with the persons in charge of the services (departments) of the establishment.

You can fulfill the online questionnaire below
You can download it in PDF format by clicking here.
Once completed we thank you for sending it by mail to M. le Directeur, Centre Hospitalier LC Fleming – BP 381 – Spring Concordia – 97150 Saint Martin.

According to the law, the information collected (taken in) within the framework of the treatment (processing) of the complaint will serve only for examination of this one and all the measures will be taken to protect the confidentiality of it.

Completar el formulario de registro de la expresion del usuario

Identification of the plaintiff

Last name*

Please mention your last name

Wife's name

Invalid Input

First name(s)

Invalid Input

Home phone

Invalid Input

Mobile phone

Invalid Input

E-mail*

Please mention a valid email address

Birth date

Invalid Input

Profession

Invalid Input

Address

Invalid Input

Mode and type of the reception

Filing of a complaint*

Please select a mode

If you have filled a complaint, date of filing

Invalid Input

Identification of the service (department)

Patient file number

Invalid Input

Service

Invalid Input

Room Number

Invalid Input

Person(s) concerned

Invalid Input

Motive of the complaint

You are filing this complaint as

Victim

Witness

Close to the Victim

Legal representative of the victim

Please specify your position in the company

What is the object of your complaint ?

Invalid Input

Pursued purpose

Invalid Input

Date of the facts (of the event)

Invalid Input

Moment of the facts

In the morning

Noon

Evening

Invalid Input

The hour of the facts (if possible)

Invalid Input

I consent to the Medical Center of Saint Martin collecting, processing and using my personal data in connection with this form as mentioned in the privacy policy. *

Veuillez consentir à l'utilisation de vos données

Medical Center of Saint Martin

Louis Constant Fleming - F.W.I

Satisfaction Questionnaire

Online payment

Europe's commitment to Saint-Martin

User recording of expression

Identification of the plaintiff

Mode and type of the reception

Identification of the service (department)

Motive of the complaint

Satisfaction questionnaire...

Contact us