Complaints form | St Hilary Group Practice

Complaints

Are you making this complaint for yourself, or on behalf of someone else?

I am making this complaint for myself

I am making this complaint on behalf of someone else

Your name

First

Last

Your date of birth

Your email address

Your telephone number

How would you prefer to be contacted?

By phone

By email

No preference

Their name

First

Last

Their date of birth

Is the patient aware you are submitting this complaint on their behalf?

Yes, the patient is aware

No, the patient is unaware

Brief reason for the patient being unaware of this complaint

Date of incident

Time of incident

Details of complaint

If you are human, leave this field blank.