Complaints Form

Please read our Complaints Procedure before completing this form

Complaints

Are you the patient?

Yes

Patient Details

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Your named GP

Details of your Complaint *

If possible, please include the date and time of the incident, as well as the names of those involved (if known).

Your confirmation *

I understand the practice complaints procedure and timelines to be followed.

Patient Details

First Name *

Last Name *

Email *

Date of birth *

Please use format day/month/year e.g. 12/05/1979

Phone Number *

Do you (the patient) authorise this complaint to be made on your behalf by the nominate person named below?

Yes I do

No I do not

Do you agree that the Practice may disclose the necessary confidential information to answer the complaint?

Yes I do

No I do not

Name of nominated person

Phone Number of Nominated Person *

Your named GP

Details of the Complaint *

If possible, please include the date and time of the incident, as well as the names of those involved (if known).

Your confirmation *

I understand the practice complaints procedure and timelines to be followed.

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Your consent *

I consent to the Practice collecting and storing my data from this form.

If you are human, leave this field blank.

Complaints Form

Patient Details

Patient Details

Privacy Policy

Park Practice

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