The Hollies Surgery Online Complaints Form

The Hollies Surgery Complaint Form

Complainant’s details

Name

First Last

Address

Street Address Address Line 2 City Postcode

Telephone number

Patient details (If different from above)

Name

First Optional Last Optional

Address

Street Address Optional Address Line 2 Optional City Optional Postcode Optional

Telephone number Optional

Summary of complaint (ie. What is it you most wish to complain about?)

Date Optional

Time

Place Optional

Identify member(s) of the Practice Optional

Full description of event(s) (i.e. the fact and circumstances giving rise to your complaint)

Complainant’s signature ( Full Name)

Date

Patients Consent

I hereby authorise the above complaint to be made and I agree that members of the Practice staff may disclose (in so far only as it is necessary to do so to answer the complaint) confidential information about me which I provided to them Optional

Patients signature ( Full Name) Optional

Date Optional