Complaint Form Please ensure you have read our Feedback and Complaints Policy before completing this form. Complaints Form Are you completing this form on behalf of someone else? I am completing this form on behalf of myself I am completing this form on behalf of someone else Patient's Name First Last Patient's Date of Birth DD slash MM slash YYYY Patient's Address Street Address Address Line 2 City Post Code Email Your Name First Last Your Address Street Address Address Line 2 City Post Code Can you tell us when the incident took place?Is the complaint about a person? Yes No If yes, please provide a name or role if knownCould you describe a brief overview or summary of your concerns, and can you explain to us what are you unhappy with?IF YOU ARE COMPLAINING ON BEHALF OF A PATIENT OR YOUR COMPLAINT OR 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.Consent 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 this person to complain on my behalf.This authority is for: an indefinite period a limited period only Where a limited period applies, this authority is valid until: DD slash MM slash YYYY Signature of patient onlyDate DD dash MM dash YYYY Comments OptionalThis field is for validation purposes and should be left unchanged.
