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Home
About us
Treatments
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Contact us
Your Experience
Your Experience
Your Experience
alunadigitalmarketing
2022-10-27T08:34:02+00:00
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Your Little Smiles Experience
When filling out this form, you can request help of a Little Smiles team member or a trustee person.
Date of the occurrence you are reporting:
Patient information
Name
*
First
Last
Email Address
*
Address
Address Line 1
City
State / Province / Region
Phone
Who is submitting the Little Smile Experience form (incident/complaint/improvement suggestion)?
*
Patient
Patient representative or guardian
A patient representative may be relative(s) of a deceased patient (spouse, partner or life partner, parent, child, brother or sister); The person to whom the patient has issued an order to complain and written authorization to do so.
Name
First
Last
Email Address
Address
Address Line 1
City
State / Province / Region
Phone
Relation to patient
The Little Smiles Experience is about (cross what applies; multiple choices are possible)
Communication skills of a Little Smiles member
Opening hours
(Telephone) Accessibility
Organization of the dental practice
Incident/near incident
Other (please specify in the field below)
Did anyone witness your Little Smiles Experience?
Yes
No
Witness information
Name
First
Last
Email Address
Phone
Description of the Little Smiles Experience (incident/complaint/improvement suggestion)?
(If the writing space is insufficient, you can add page(s) of your own)
Do you feel the neccesity to bring the Little Smiles Experience (incident/complaint/improvement suggestion)forward, with a member of the Experience committee?
Yes
No
To whom or to what is your Little Smiles Experience (incident/complaint/improvement suggestion) directed?
Name and position
Signature by patient/contact person
Signature by patient/contact person
Date/Place
Must be completed, otherwise your Little Smiles Experience cannot be processed*
Full Name
Must be completed, otherwise your Little Smiles Experience cannot be processed*
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