The lansdowne surgery complaint form

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: [phone]

E-mail: [e-mail]

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: [phone] (24 hour Freephone number

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