{"id":12715,"date":"2024-12-30T12:35:22","date_gmt":"2024-12-30T12:35:22","guid":{"rendered":"https:\/\/drducuclinics.com\/?page_id=12715"},"modified":"2024-12-30T12:48:01","modified_gmt":"2024-12-30T12:48:01","slug":"patient-complains","status":"publish","type":"page","link":"https:\/\/drducuclinics.com\/fr\/patient-complains\/","title":{"rendered":"Patient Complains"},"content":{"rendered":"\n<br><style>\r\n    \/* General *\/\r\n    .center {\r\n        text-align: center;\r\n    }\r\n    .page-header {\r\n        display: none;\r\n    }\r\n    .mt-5 {\r\n        margin-top: 5px;\r\n    }\r\n    .mt-10 {\r\n        margin-top: 10px;\r\n    }\r\n    .mt-15 {\r\n        margin-top: 15px;\r\n    }\r\n    .w-33 {\r\n        width: 33%;\r\n    }\r\n    .w-50 {\r\n        width: 50%;\r\n    }\r\n    .w-100 {\r\n        width: 100%!important;\r\n    }\r\n    .cg-50 {\r\n        column-gap: 50px;\r\n    }\r\n    .color-light-grey {\r\n        color: #757579!important;\r\n    }\r\n    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}\r\n<\/style>\r\n\r\n<form class=\"gp-custom-form\" action=\"\" method=\"POST\">\r\n    <!-- Header Section -->\r\n    <div class=\"header-section\">\r\n        <div class=\"center\">\r\n            <h1 class=\"big-header\">Patient Complaint Form<\/h1>\r\n            <h1 class=\"big-header\">NKD MEDICAL LTD<\/h1>\r\n        <\/div>\r\n    <\/div>\r\n\r\n    <!-- Date Section -->\r\n    <div class=\"date-section\">\r\n        <label for=\"date\">Date:<\/label>\r\n        <input type=\"date\" id=\"date\" name=\"pq_date\" value=\"\">\r\n    <\/div>\r\n\r\n    <p class=\"mt-15\"><b>Person Registering the Complaint:<\/p>\r\n\r\n    <div class=\"table-container\">\r\n        <table class=\"rating-table\">\r\n            <tbody>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_person_first_name\" class=\"w-100\" name=\"pq_person_first_name\" value=\"\" placeholder=\"First Name\"><\/td>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_person_last_name\" class=\"w-100\" name=\"pq_person_last_name\" value=\"\" placeholder=\"Last Name\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td colspan=\"2\"><input type=\"text\" id=\"pq_person_address\" class=\"w-100\" name=\"pq_person_address\" value=\"\" placeholder=\"Address\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_person_daytime_phone\" class=\"w-100\" name=\"pq_person_daytime_phone\" value=\"\" placeholder=\"Daytime Phone Number + Area Code\"><\/td>\r\n                    <td class=\"w-50 w-50-mobile\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_person_evening_phone\" class=\"w-100\" name=\"pq_person_evening_phone\" value=\"\" placeholder=\"Evening Phone Number + Area Code\"><\/td>\r\n                    <td class=\"w-50 w-50-mobile\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td colspan=\"2\"><input type=\"text\" id=\"pq_person_email_address\" class=\"w-100\" name=\"pq_person_email_address\" value=\"\" placeholder=\"Email Address\"><\/td>\r\n                <\/tr>\r\n            <\/tbody>\r\n        <\/table>\r\n    <\/div>\r\n\r\n    <p class=\"mt-15\"><b>Patient Information (if other than the person registering the complaint):<\/p>\r\n\r\n    <div class=\"table-container\">\r\n        <table class=\"rating-table\">\r\n            <tbody>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_patient_first_name\" class=\"w-100\" name=\"pq_patient_first_name\" value=\"\" placeholder=\"First Name\"><\/td>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_patient_last_name\" class=\"w-100\" name=\"pq_patient_last_name\" value=\"\" placeholder=\"Last Name\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td colspan=\"2\"><input type=\"text\" id=\"pq_patient_address\" class=\"w-100\" name=\"pq_patient_address\" value=\"\" placeholder=\"Address\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_patient_daytime_phone\" class=\"w-100\" name=\"pq_patient_daytime_phone\" value=\"\" placeholder=\"Daytime Phone Number + Area Code\"><\/td>\r\n                    <td class=\"w-50 w-50-mobile\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\"><input type=\"text\" id=\"pq_patient_evening_phone\" class=\"w-100\" name=\"pq_patient_evening_phone\" value=\"\" placeholder=\"Evening Phone Number + Area Code\"><\/td>\r\n                    <td class=\"w-50 w-50-mobile\"><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td colspan=\"2\"><input type=\"text\" id=\"pq_patient_email_address\" class=\"w-100\" name=\"pq_patient_email_address\" value=\"\" placeholder=\"Email Address\"><\/td>\r\n                <\/tr>\r\n            <\/tbody>\r\n        <\/table>\r\n    <\/div>\r\n\r\n    <p class=\"mt-15\"><b>DETAILS OF THE COMPLAINT<\/p>\r\n    <p class=\"mt-15\"><b>Provide Details of your concern including the following as appropriate\/applicable<\/p>\r\n\r\n    <div class=\"table-container\">\r\n        <table class=\"rating-table inline-inputs-table\">\r\n            <tbody>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\"><label for=\"pq_date_incident\">Date of Incident:<\/label><input type=\"date\" id=\"pq_date_incident\" name=\"pq_date_incident\" value=\"\"><\/td>\r\n                    <td class=\"w-50 w-50-mobile\"><label for=\"pq_time_incident\">Time of Incident:<\/label><input type=\"time\" id=\"pq_time_incident\" name=\"pq_time_incident\" value=\"\" \/><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <div class=\"checkbox-group\">\r\n                            <label>Was this a CLINIC visit:<\/label>\r\n                            <label><input type=\"radio\" name=\"pq_clinic_visit\" value=\"yes\" > Yes<\/label>\r\n                            <label><input type=\"radio\" name=\"pq_clinic_visit\" value=\"no\" > No<\/label>\r\n                        <\/div>\r\n                    <\/td>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <div class=\"checkbox-group\">\r\n                            <label>Was this a PROGRAM visit:<\/label>\r\n                            <label><input type=\"radio\" name=\"pq_program_visit\" value=\"yes\" > Yes<\/label>\r\n                            <label><input type=\"radio\" name=\"pq_program_visit\" value=\"no\" > No<\/label>\r\n                        <\/div>\r\n                    <\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td colspan=\"2\"><label>Name of the Healthcare team member(s) involved:<\/label><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_members_involved_doctor\" class=\"w-100\" name=\"pq_members_involved_doctor\" value=\"\" placeholder=\"Doctor:\">\r\n                    <\/td>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_members_involved_nurse\" class=\"w-100\" name=\"pq_members_involved_nurse\" value=\"\" placeholder=\"Nurse:\">\r\n                    <\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_members_involved_receptionist\" class=\"w-100\" name=\"pq_members_involved_receptionist\" value=\"\" placeholder=\"Receptionist:\">\r\n                    <\/td>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_members_involved_other1\" class=\"w-100\" name=\"pq_members_involved_other1\" value=\"\" placeholder=\"Other:\">                        \r\n                    <\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_members_involved_other2\" class=\"w-100\" name=\"pq_members_involved_other2\" value=\"\" placeholder=\"Other:\">\r\n                    <\/td>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_members_involved_other3\" class=\"w-100\" name=\"pq_members_involved_other3\" value=\"\" placeholder=\"Other:\">\r\n                    <\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td colspan=\"2\">\r\n                        <textarea class=\"w-100\" rows=\"6\" name=\"pq_members_involved_complain\" placeholder=\"What is your complaint\/concern: (continued on reverse)\"><\/textarea>\r\n                    <\/td>\r\n                <\/tr>\r\n            <\/tbody>\r\n        <\/table>\r\n    <\/div>\r\n\r\n    <div class=\"table-container\">\r\n        <table class=\"rating-table inline-inputs-table\">\r\n            <tbody>\r\n                <tr>\r\n                    <td colspan=\"2\">\r\n                        <textarea class=\"w-100\" rows=\"6\" name=\"pq_efforts\" placeholder=\"Describe any efforts you have made to resolve this matter:\"><\/textarea>\r\n                    <\/td>\r\n                <\/tr>\r\n            <\/tbody>\r\n        <\/table>\r\n    <\/div>\r\n\r\n    <div class=\"table-container\">\r\n        <table class=\"rating-table inline-inputs-table\">\r\n            <tbody>\r\n                <tr>\r\n                    <td colspan=\"2\">\r\n                        <textarea class=\"w-100\" rows=\"6\" name=\"pq_result_outcome\" placeholder=\"Please describe the result or outcome that you seek:\"><\/textarea>\r\n                    <\/td>\r\n                <\/tr>\r\n            <\/tbody>\r\n        <\/table>\r\n    <\/div>\r\n\r\n    <div class=\"table-container\">\r\n        <table class=\"rating-table inline-inputs-table\">\r\n            <tbody>\r\n                <tr>\r\n                    <td>\r\n                        <div class=\"question-section-inline\">\r\n                            <label class=\"w-50 mb-0\">Do you consider this matter urgent<\/label>\r\n                            <div class=\"checkbox-group cg-50\">\r\n                                <label>\r\n                                    <input type=\"radio\" name=\"pq_urgent_matter\" value=\"yes\" > Yes\r\n                                <\/label>\r\n                                <label>\r\n                                    <input type=\"radio\" name=\"pq_urgent_matter\" value=\"no\" > No\r\n                                <\/label>\r\n                            <\/div>  \r\n                        <\/div>\r\n                    <\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td colspan=\"2\">\r\n                        <textarea class=\"w-100\" rows=\"6\" name=\"pq_urgent_matter_explanation\" placeholder=\"If yes, please explain why:\"><\/textarea>\r\n                    <\/td>\r\n                <\/tr>\r\n            <\/tbody>\r\n        <\/table>\r\n    <\/div>\r\n\r\n    <!-- <p class=\"mt-15\">Please forward the completed form to<\/p>\r\n    <p class=\"mt-15 mb-0\">ALINA FJODROVA<\/p>\r\n    <p class=\"mb-0\">89-91 Wardour Street<\/p>\r\n    <p class=\"mb-0\">Soho, London<\/p>\r\n    <p>W1F 0UB<\/p>\r\n    <p class=\"mt-15 mb-0\"><a href=\"mailto:alina@drducuclinics.com\" class=\"text-decoration-none\">EMAIL: alina@drducuclinics.com<\/a><\/p>\r\n    <p><a href=\"tel:447867794912\" class=\"text-decoration-none\">CONTACT: +44 7867794912<\/a><\/p> -->\r\n\r\n    <div class=\"table-container mt-15\">\r\n        <table class=\"rating-table inline-inputs-table\">\r\n            <tbody>\r\n                <tr>\r\n                    <td colspan=\"2\"><label><b>FOR OFFICE USE ONLY<\/b><\/label><\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_complaint_received_by\" class=\"w-100\" name=\"pq_complaint_received_by\" value=\"\" placeholder=\"Complaint received by:\">\r\n                    <\/td>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <label for=\"pq_complaint_received_date\">Date:<\/label><input type=\"date\" id=\"pq_complaint_received_date\" name=\"pq_complaint_received_date\" value=\"\">\r\n                    <\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <input type=\"text\" id=\"pq_complaint_investigated_by\" class=\"w-100\" name=\"pq_complaint_investigated_by\" value=\"\" placeholder=\"Complaint Investigated by:\">\r\n                    <\/td>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <label for=\"pq_complaint_investigated_date\">Date:<\/label><input type=\"date\" id=\"pq_complaint_investigated_date\" name=\"pq_complaint_investigated_date\" value=\"\">\r\n                    <\/td>\r\n                <\/tr>\r\n                <tr>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <label for=\"pq_date_response\">Date response sent to client:<\/label><input type=\"date\" id=\"pq_date_response\" name=\"pq_date_response\" value=\"\">\r\n                    <\/td>\r\n                    <td class=\"w-50 w-50-mobile\">\r\n                        <div class=\"checkbox-group\">\r\n                            <label>Resolved<\/label>\r\n                            <label><input type=\"radio\" name=\"pq_solved_problem\" value=\"yes\" > Yes<\/label>\r\n                            <label><input type=\"radio\" name=\"pq_solved_problem\" value=\"no\" > No<\/label>\r\n                        <\/div>\r\n                    <\/td>\r\n                <\/tr>\r\n            <\/tbody>\r\n        <\/table>\r\n    <\/div>\r\n\r\n    <input class=\"mt-5\" type=\"submit\" value=\"submit\">\r\n<\/form>\r\n\r\n\r\n<script>\r\n<\/script>\r\n\r\n\n\n\n\n<p><\/p>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-12715","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.4 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ 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