Complaints Form Your Name Date of Birth Contact Number Email Optional Are you complaining on behalf of someone else? Yes No If you are complaining on behalf of someone else, we will require their signed consent that they are happy for you to make a complaint on their behalf. Please visit the surgery or contact us to recieve a paper consent form.Date Problem First Occurred If the problem occured in surgery, which site was this at? Trinity Medical Centre Optional Sandal Castle Medical Centre Optional Please tell us which staff group this involves? Administration Team (Emails, Reports, Online Messages, Registrations, Referrals, Letters, Appointment Booking) Reception Team (Phone calls, prescriptions, requesting appointment) Clinical Staff (Doctors, Nurses, HCA’s, Paramedics, any other clinical staff) Management Other Unsure Type of Complaint Appointment Availability Appointment Obtaining Clinical Treatment Communications Inaccurate/Incorrect Medical Records Staff Behaviour Prescription Other Details of your complaint
