We work hard to deliver the best possible medical and non-medical care. However, if you feel you have a genuine complaint regarding the level of care received, we invite you to follow our Complaints Procedure.

You can also complete the below form.

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Complaint Details

Name of Surgery/Service:

Patient Name (if different to complainant):

Patient Date of Birth:

Please use this date format: DD/MM/YYYY.

Relationship to complainant:

Date of incident:

Please use this date format: DD/MM/YYYY.

Time of incident:

Staff members involved (if known):

Brief description of incident:

Expected outcome: for completion by complainant

Explanations regarding:

Please write in note form the key issues you would like an explanation for.

Apology for:

Please write in note form the issues you would like an apology for.

Other outcome:

Please write here any other outcome that you would like to see as a result of our investigation of your complaint.

Complainant's signature:

By ticking this box I am signing as the complainant