PATIENT COMPLAINT FORM

We will acknowledge your complaint within 3 working days and aim to have fully investigated within 30 working days of the date it was received. If we expect it to take longer we will explain the reason for the delay and tell you when we expect to finish. When we look into your complaint, we will investigate the circumstances; make it possible for you to discuss the problem with those concerned; make sure you receive an apology if this is appropriate, and take steps to make sure any problem does not arise again.

You will receive a final letter setting out the result of any practice investigations.

Last Updated: 28/04/2022

YOUR DETAILS

Patient Full Name: *

DATE OF BIRTH *

ADDRESS: *

PHONE NUMBER? *

EMAIL ADDRESS? *

COMPLAINT DETAILS: (INCLUDE DATES, TIMES AND NAME OF PRACTICE PERSONNEL, IF NAME)

COMPLAINT DETAILS: (INCLUDE DATES, TIMES AND NAME OF PRACTICE PERSONNEL, IF NAME) *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. HIS IS TO CONFIRM YOU ARE REGISTERED WITH TEH PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YPUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNER IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

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PATIENT COMPLAINT FORM

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