Complaints Form

Last Updated: 21/07/2021

Your Details:

Please answer all questions.

Full Name of Complainant *

Preferred Contact Number *

Email Address *

Full Address *

Complaining on behalf of someone else?

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 patients consent in writing - this can be scanned and emailed to colton.andthegrange@nhs.net or dropped into the practice. Please complete the below section if the above applies.

Full Patient Name

Patient date of birth

Patient Full Address

Complaint Details

Please provide a summary of your complaint including dates, times, location, name or staff involved *if known* to assist our investigation.

Date of incident *if known*

Time of incident *if known*

Location of incident

Your Complaint *

Help us to Help you

To assist us with writing our response, please tell us if you have any specific questions that you would like us to answer.

Please list below

End Section

We will make every effort to try and resolve the complaint to your satisfaction. We will acknowledge your complaint within 7-14 working days to inform you that your complaint has been received and investigated.

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Complaints Form

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