Register a complaint

All fields marked with (*) are mandatory.

Patient Data

ID Type *

Patient's document number *

Patient's full name *

Applicant Type *

Service where the event occurred *

Email *

Phone / Cellphone *

Insurer *

Is the patient the same as the petitioner?

If checked, the petitioner data will be automatically filled with the patient data.

Data of the person registering the complaint

Petitioner's Document Type

Petitioner's Document Number

Petitioner's Names

Petitioner's Address

Petitioner's Email

Petitioner's Cellphone

Description of the Facts

Event Details *

Dear user, if you wish to attach any support or document to your statement, please select a file (Select the files you deem necessary)

Click to upload or drag and drop

PDF, Word, Excel, PowerPoint, Images (Max. 5 files, 25MB total)

* I authorize the processing of my personal data, in accordance with Law 1581 of 2012 and the personal data protection and processing policy of Clínica De Occidente.