The lansdowne surgery complaint form



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THE LANSDOWNE SURGERY


COMPLAINT FORM



Complainant’s details Patient’s details (where different)
Name ……………………………………………… Name ………………………………………………
Address …………………………………………… Address ……………………………………………
……………………………………………………... ……………………………………………………...
Date of birth ……………………………………… Date of birth ……………………………………...

Usual Practitioner ………………………………. Usual Practitioner ……………………………….

Where the complainant is NOT the patient:
I …………………………………… Authorise the complaint set out overleaf to be made on my behalf and I agree that the practice may disclose to ……………………..

(only so far as is necessary to answer the complaint) confidential information about me which I provided to them.


Patient’s signature ……………………………………… Date ……………………….


Name and address ………………………………………………………………………



Contact Details
The Practice Manager

The Lansdowne Surgery

Waiblingen Way

DEVIZES


Wiltshire

SN10 2BU


Telephone: 01380 724883

E-mail: Lansdownesurgery@nhs.net



Patients Advice and Liaison Service for Wiltshire CCG

NHS Bath and North East Somerset

Trust HQ

St Martin’s Hospital

Clara Cross lane

BATH


BA2 5RP

Telephone: 0800 3897671 (24 hour Freephone number


Details of complaint (including date(s) of events and persons involved). Continue on a separate sheet if necessary.




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