Complaint Form

Complete this form if you wish to submit a formal complaint to the surgery. Please note, if you are submitting a complaint on behalf of someone else, both parties may need to be contacted by the practice to verify that the complainant has consent to make the complaint on the patients behalf.

Last Updated: 22/04/2021

Complainant's Details

Name *

Address *

Telephone number *

Email Address

Patient's Details

If different from above.

Name

Address

Telephone number

Email Address

I authorise a complaint to be made on my behalf by and agree that the practice may disclose to the complainant (only in so far as is necessary to answer the complaint) confidential information about me which I provided to them.

Yes No

WHEN IS BEST TO CONTACT YOU AND YOUR REPRESENTATIVE?

Complaint

Usual GP of patient

Problem/Complaint *

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Complaint Form

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