Your Experience -

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

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*

Your Experience

Your Experience

Your Little Smiles Experience

Patient information

Witness information

Signature by patient/contact person

Contact details

Your experience

Social media