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Something went wrong ? - Patient's notice
Mandatory fields are marked with an asterisk (*) Form date: 18.4.2019 
Date and time of the incident(*)
date: time: :
Where event happened
What happened and how did it happen? What were the consequences? (*)

What can be done to prevent the incident.
 
If you want a response to your notice, please leave your contact information:
E-mail address
Other contact information

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