Something went wrong ? - Patient's notice
Mandatory fields are marked with an asterisk (*)
Form date: 7.6.2023
Date and time of the incident
(*)
Date
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Time:
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Incident location
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
Contact information of the notifier
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