Complaint Form

If you would like to submit a complaint to the practice, please complete this form.

Complaint Form

If you are human, leave this field blank.

Complainant Details

Full Name: *

Contact number:

Today's Date:

Address (including postcode):

Complaint Details

Include dates, times and names of practice personnel if known:

Signed: *

Date:

Are you complaining on behalf of another patient? *

Yes

Does your complaint involve the medical care of another patient? *

Yes

Patient Third-Party Consent

Patient name:

Patient telephone number:

Patient address:

If you are complaining on behalf of a patient, or your complaint/enquiry involves the medical care of a patient, then the consent of the patient will be required. Please obtain the patient's signed consent below:

I fully consent to my Doctor releasing information to, and discussing my care and medical records with the person named above in relation to this complaint only, and I wish for this person to complain on my behalf.

This authority is for:

An indefinite period

A limited period only

This authority is valid until:

Signed: (patient only) *

Date:

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Complainant Details

Complaint Details

Patient Third-Party Consent