Complaints Form Please refer to the Complaints Leaflet for further information our Complaint Procedure. Complainant’s (Your) details:Name First Last Date of Birth Day Month Year Address Street Address Address Line 2 City Post code Contact NumberPatient’s details (if different from above):Name First Last Date of Birth Day Month Year Address Street Address Address Line 2 City Post code Contact NumberSummary of complaint: (include dates, times, places and names of practice staff involved plus a full description of events – continue overleaf if necessaryWhat would you like to happen as a result of your complaint? OptionalAre you making a complaint on behalf of someone else? Yes No 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, and I wish this person to complain on my behalf.This authority is for An indefinite period For a limited period only Where a limited period applies, this authority is valid until… Month Day Year
