Patient Complaint Form

Full Name

Address:

Day Phone

Evening Phone

Your email address

If you are complaining on someone else's behalf please provide:

Name

Relationship to the patient

Is the patient aware that you are complaining on their behalf?

Yes

If someone is representing you (e.g. solicitor or advocate) please provide:

Representative’s name

Organisation

Postal address

Contact number

What happened?

Where did it happen?

When did it happen?

Did anyone witness what happened?

What is your complaint about (e.g. a person, process, service)?

Is there anything else you’d like to tell us about the event?

What would you like to see happen as a result of this complaint?

Have you tried to resolve your complaint in any other way (e.g. by obtaining a second medical opinion)? If so, please describe this.