Complaint Form

If you are making a complaint on behalf of a third party please include their name, date of birth, address and contact information below

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Complaint

Your Complaint *

What do you recommend we can do to help resolve the issue? *

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

I consent to the practice collecting and storing my data from this form.

How the complaints procedure works

If you would like to discuss the procedure further please contact the surgery

I confirm my understanding that my complaint will follow the formal procedure policy at the Practice. *

Yes

I confirm that I have considered all other forms of contacting the surgery about my complaint including the informal process that the Practice provides. *

Yes

I confirm that I understand the Practice will acknowledge my complaint within 3 working days and will have looked into the complaint usually within 10 working days. This will depend on the nature of the complaint and therefore does not mean you will receive a response in this time. (Weekends do not count as weekdays) *

Yes

I confirm my understanding that once my complaint has been investigated, I will receive a response from the Practice detailing their findings and, where appropriate, provide apologies and information about the results of the complaint. *

Yes

I confirm my understanding that if I am not happy with the way my complaint has been dealt with, I can complain to the relevant ombudsman *

Yes

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Page last reviewed: 10 February 2023
Page created: 10 January 2023

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Complaint Form

Complaint Form

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