Complaints Form - Ouse Valley Practice

Please refer to the Complaints Leaflet for further information our Complaint Procedure.

Complainant’s (Your) details:

Name

First Last

Date of Birth

Address

Street Address Address Line 2 City Post code

Contact Number

Patient’s details (if different from above):

Name

First Optional Last Optional

Date of Birth

Address

Street Address Optional Address Line 2 Optional City Optional Post code Optional

Contact Number Optional

Summary of complaint: (include dates, times, places and names of practice staff involved plus a full description of events – continue overleaf if necessary

What would you like to happen as a result of your complaint? Optional

Are you making a complaint on behalf of someone else?

Yes

I fully consent to my Doctor releasing information to, and discussing my care and medical records with the person named above in relation to this complaint, and I wish this person to complain on my behalf.

This authority is for

An indefinite period

For a limited period only

Where a limited period applies, this authority is valid until…