Complaint Form Please ensure you have read our Feedback and Complaints Policy before completing this form. Complaints Form Phone OptionalThis field is for validation purposes and should be left unchanged.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
