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.

Patient or Third Party Complaints

Patient or Third Party Complaints

Personal Details

Are you making the complaint on behalf of: *

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.

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

Complaint Details