Complaints and feedback form Tell us what you think. Please read the Complaints and Feedback section for more information. Patient Name First Last Date of Birth DD slash MM slash YYYY Patient's Address (including postcode)Complaint or Compliment DetailsPlease include dates, times, the name of the GP practice or Bevan service and the names of Bevan staff involved in your complaint or compliment.Date of signature Optional MM slash DD slash YYYY If you are completing the form on behalf of the person named above then please fill in your details below.Your Name First Optional Last Optional If you are completing on behalf of a patient, please completeYour Phone Number OptionalYour Email Optional Your Relationship to Patient OptionalYou need permission to feedback or complain on this person’s behalf.Do you have permission to feedback/complain on this person’s behalf? Yes Optional No Optional We will contact the person to check they have given permission.
