PRACTICE COMPLAINTS FORM
(in confidence)

Please print off to complete.

To be completed by the Complainant.

Complainantís details:

Name....................................................................

Telephone No....................................................

Address...........................................................................................

 

Patients details if different from above (please make sure they complete consent form)

Name....................................................................

Telephone No ..................................................

Address.........................................................................................................................................

Date of Birth.........................................................

GP........................................................................

Details of complaint (including date(s) of events and persons involved).

 

 

 

 

 

 

 

 

 

Complainants Signature...........................................................Date...................................................

 

 

 

 

THIRD PARTY CONSENT

 

 

 

1, (Patients Name)...............................................................................

authorise the complaint set out overleaf to be made on my behalf by my representative

(Complainants name)......................................................................................

I agree that the Practice may disclose to my representative named above such information held at the Practice about myself that is considered by the Practice to be necessary in resolving this complaint.

 

Signed (patientís signature).............................................................................

Last updated 16 February 2014

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