Effective Date:

ULTRA LASIK EYE CENTER

01-03-2022
Document Code:
Document Title: ULEC –QSF-CS-01
CUSTOMER COMPLAINT FORM Rev.
Ref # : CS 1
No.01

SECTION 1 Customer’s Name and Address:

DATE:

TO:

SECTION 2 (To Be Filled By Originator and sent to the concerned Department Head)
Description of complaint:

Signature: Date:
SECTION 3
Solution ( Action to be decided by Department Head)

SECTION 4 (To Be Completed By Officer / Engineer / Manager and forwarded to the concerned Dept
Head)

ACTION COMPLETED: DATE: SIGNATURE:

SECTION 5
Close Complaint  Yes  No
SECTION 6 (To be filled by the Department Head and forwarded to Management)
ROOT CAUSES OF THE PROBLEM (INVESTIGATION)

Signature: Date:
SECTION 7 (To Be Completed By Management Representative)

ACTION VERIFIED

Signature: Date:

IS CORRECTIVE ACTION REQUIRED

 Yes  No (If yes please use the CAR form)