Complaint Form - Burnett Edgar Medical Centre

Who is completing this form?(Required)

Patient (complainant)

Somebody else (third party)

Patient Details

Title(Required)

First Name(Required)

Surname(Required)

Previous Surname

Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City Postcode

Telephone Number(Required)

NHS Number (if known)

Section 2: Third Party Details

Title(Required)

First Names(Required)

Surname(Required)

Address(Required)

Street Address Address Line 2 City Postcode

Telephone Number(Required)

Complaint Details

Please give ful details of the complaint below, including dates, times, locations and names of any practice staff (if known).(Required)

Declaration

I hereby authorise the individual detailed in Section 2 to act on my behalf in making this complaint and to receive such information as may be considered relevant to the complaint. I understand that any information given about me is limited to that which is relevant to the subsequent investigation of the complaint and may only be disclosed to those people who have consented to act on my behalf.

This authority is for :(Required)

an indefinite period

for a limited period only* (Where a limited period applies)

Date from(Required)

Date to(Required)

Signature

Full Name(Required)

Date(Required)