Complaints Form

We make every effort to give the best service possible to everyone who attends our practice.

However, we are aware that things can go wrong resulting in a patient feeling that they have a genuine cause for complaint. If this is so, we would wish for the matter to be settled as quickly, and as amicably, as possible.

To pursue a complaint please complete this form and our patient liaison officer will deal with your concerns appropriately.

We will aim to acknowledge your complaint within 2 working days.

Last Updated: 11/04/2024

Your Details

Name

Date of Birth
For example, 15 3 1984

Day

Month

Year

Phone Number (optional)

Email Address
Complaint Details

Patient's name (if different from above) (optional)

Patient's Date of Birth (optional)

Summary of Complaint - Please provide as much detail as possible including the date, time, place, and staff involved

WHERE THE COMPLAINANT IS NOT THE PATIENT - (optional)

I (the above named patient) hereby authorise the above complaint to be made and I agree that members of the practice staff may disclose (in so far only as it is necessary to do so to answer the complaint) confidential information about me which I provided to them.

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.

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

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Complaints Form

Your Details

Complaint Details