Make Complaint Form

Please read our complaints policy before completing this form.

Complaints

Who is making the complaint?

I am the patient making the complaint

I am the making the complaint on behalf of the patient as their representative

Patient details

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Usual GP

Details of patient’s representative

First Name of representative *

Last Name of representative *

Email of representative

Date of birth of represetative *

Please use format day/month/year e.g. 12/05/1979

Phone Number of representative *

Address of representative

Signature of representative

Clear

Details of the complaint

Please provide as much information as possible including dates of events and names of individuals involved if known.

Patient’s Signature

Clear

Patient Declaration

I hereby authorise

the individual detailed above as my representative to act on my behalf in relation to this complaint and to receive information relevant to this.

I understand that

any information given about me is limited to that which is relevant to the subsequent investigation of this complaint

Patient’s Signature

Clear

Privacy Policy

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.

Your confirmation *

I consent to the practice collecting and storing my data from this form.

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Patient details

Details of patient’s representative

Patient Declaration

Privacy Policy

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