Complaint Form

We understand that sometimes things don’t go as expected, and we want to address any issues you may have encountered promptly and effectively. If you’ve experienced a serious problem or have concerns, please let us know by filling out the form below. We are committed to resolving your issue as quickly as possible and appreciate the opportunity to make things right.

About You

Name

First Last

Date of Birth  Optional

MM slash DD slash YYYY

NHS Number (If known)  Optional

Email Address

This is how we will contact you regarding your complaint. Please ensure this address is private and safe for you to receive communications.

Your Visit

This sections helps us to investigate occurrences on our end. With this information we can find appointments, phone calls and other events.

Date of Visit  Optional

MM slash DD slash YYYY

Time of Visit

Hours  Optional

:

Minutes  Optional

AM PM AM/PM  Optional

Name of Staff Member Involved  Optional

(If applicable)

Your Complaint

Nature of your complaint

Please provide as much information as you can to help us investigate your issue.

Type of Issue

Appointment Scheduling

Waiting Time

Communication

Treatment/Care

Staff Attitude

Prescription Issues

Facilities

IT

Other

How did the issue affect you?  Optional

Severity and Impact

How serious do you consider this issue to be?

Minor  Optional

Moderate  Optional

Severe  Optional

Critical  Optional

Unknown / Unsure  Optional

Did this issue impact your health or wellbeing?

Yes  Optional

No  Optional

How did this issue impact your health or wellbeing?  Optional

Resolutions

Have you previously reported this issue to anyone at the surgery?

Yes

No

To whom did you report your issue?  Optional

What was the response to your report?  Optional

Desired Outcome

Apology

Explanation

Change in Procedure

Further Investigation

Other

What outcome are you seeking from this complaint?

Please specify what 'Other' outcome you are hoping for  Optional

Anything else to tell us?

Any additional comments or suggestions?  Optional

Confidentiality and Consent

Do you consent to your complaint being shared with the relevant parties within the surgery for resolution purposes?

Yes

No

Do you consent to your anonymised complaint being used for training and quality improvement?

Yes

No

Submission Confirmation

I confirm the provided information is correct

Please confirm that the information provided is accurate to the best of your knowledge.

Patient Advice and Complaints Team

The Patient Advice Team is part of the Patient Advice and Complaints Team (PACT) and it’s role is to ensure that the NHS listens to patients, their relatives, carers and friends, and answers their questions and resolves their concerns as quickly as possible.

Feedback

There are also other ways to give feedback about your care without making a complaint, find out more about how to give us feedback on our ‘Feedback and Getting Involved’ page.