Patient or Third Party Complaints

If you or a third party (with consent from the patient) would like to submit a complaint to the practice manager, please use this form.

If you are human, leave this field blank.

Personal Details

Are you making the complaint on behalf of: *

Yourself

On behalf of someone else

If you are making a complaint on behalf of a patient or your complaint or enquiry involves the medical care of a patient, please complete your details below as the consent of the patient will be required.

Patient Name: *

Your Name: *

Your relationship to the patient: *

Your Phone Number:

NHS Number:

How to find your NHS Number

Your Address: *

Patient's Address: *

Consent and Declaration

You can grant consent to all the purposes of use, some of them, or none.

Where a patient does not grant consent then the Practice will not be able to use their personal data, except in certain limited situations, e.g, where required to do so by law, or to protect the public from serious harm.

I fully consent to my Doctor releasing information to, and discussing my care and medical records with, the person named above: *

Yes

Please specify if this authority is for an indefinite period or a limited period: *

Indefinite period

Limited period

Valid from: *

Valid until: *

Complaint Details

Please detail the complaint below, including dates, times, and the names of the practice personnel, if known: *

Patient Name: *

Patient signature: *

Date:

Tell us whether you accept cookies

Patient or Third Party Complaints