Complaint Form

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Your Name

First Last

DOB

NHS Number

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Your complaint/feedback

Have you experience this issue before? (either at this surgery or at another healthcare provider? Please provide details if it was previously resolved?

Can you help us understand what you think should have happened?

Please tell us what you want to achieve from this complaint? Common outcomes from complaints include improving our service through training, saying sorry when we have made a mistake, addressing a communication problem or exploring the issues with you in more detail.

Would you like us to review this feedback going forward as part of our learning?

Yes

Would you like us to arrange a face to face meeting with the practice manager?

Yes

Signature

Next steps and what you can expect from us

We would like to review this information as part of our ongoing commitment to improving our services. We would hope to reach a positive outcome for you and the practice and ensure that our systems are as effective as we can make them.

Yours sincerely

Complaints GP

Spring Hall Group Practice