Complaint Form

Anonymous Complaints: In the interest of fairness we cannot investigate anonymous complaints.

Note: If you are complaining on behalf of a patient or your complaint or enquiry involves the medical care of a patient then the consent of the patient will be required. Please obtain the patient’s signed consent by having them fill in the form below and returning this to the practice.

COMPLAINT FORM – PATIENT THIRD PARTY CONSENT

First Name

Last Name

Date of Birth (dd/mm/yyyy)

Phone

Full Address

Subject

Summary of complaint, please give as much information as possible

Your Signature

I consent to this message being sent electronically to the practice. I have checked that the email address and phone number supplied are correct and consent to receiving medical information via email or text.

By submitting this form you will be sending personal/sensitive information about yourself across the Internet. Please read our privacy statement to discover how we protect and manage your submitted data. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method of contacting the practice.

Complaint Form

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For Life Threatening Emergencies - Call 999 or 112