Complaint Form

Your Details

Name of Patient *

If you are completing this form on behalf of someone else what is your relationship to them ?

Has the patient given their permission ?

Date of Birth *

Name of person completing this form *

Contact Phone Number *

Contact Email Address

Complaint

Date of Complaint *

Summary of complaint - what events have lead you to your complaint *

What is the main concern ? Can you help us understand what you think should have happened

Please tell us your expected outcome from this complaint - eg provide us with feedback, help improve our service, to say sorry if we have done something wrong or highlight a training issue

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

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Page last reviewed: 02 June 2025
Page created: 06 December 2019

Complaint Form

Complaint Form

Further Information