Compliment, Concern or Complaint Form

Personal Details

Patient Full Name *

Patient Date Of Birth *

Your name if different from name above

Phone Number

Email Address

Compliment, Concern Or Complaint

I understand that this form collects my name, date of birth and any other personal information that I choose to provide. This is to confirm I am registered with the practice or identify that a third party complaint is being made; to allow the practice team to contact me and to update the medical records held by them and their partners in the NHS. I understand that I am able to read the privacy policy (located in the website footer) to discover how they protect and manage my submitted data. *

I consent to the practice collecting and storing my data from this form and understand anything not relating to this form will not be actioned

Is this a Compliment

Yes No

Is this a Concern

Yes No

Is this a Complaint

Yes No

Details of Compliment, Concern or Complaint. In cases where you are raising a concern or a complaint, please help us by providing as much information as possible, letting us know what happened, who was involved, when it happened and what you want us to do to put things right. The complaints manager, or their representative, will respond within three business days to acknowledge your concern or complaint. Where you have raised a compliment, we sincerely appreciate your kind words and acknowledgment of our efforts. Rest assured, we will share your feedback with the team. *

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Page last reviewed: 20 March 2024
Page created: 07 September 2022

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Compliment, Concern or Complaint Form

Compliment, Concern or Complaint Form

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