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Summary of complaint
What happened, what went wrong, and why are you complaining – please also provide any other information you feel is relevant to help us understand your complaint.
Are there any specific questions you would like to be addressed?*
Please state what you would like to see happen as a result of your complaint?*
About you
Please provide as many details as possible
Your name*
Date of birth:*
DD slash MM slash YYYY
NHS number (if known):
Address (Line 1)*
Address (Line 2)
City*
County*
Postcode*
Email address*
Telephone number*
Preferred method of contact:*
If you are making a complaint on behalf of another person, please provide their details
We will usually need the patient’s consent before we can release our investigation findings, however we will contact you to discuss this.
Name of patient:
Date of birth:
MM slash DD slash YYYY
NHS number
Address (Line 1)
Address Line 2
City
County
Postcode
Telephone number of patient
Please provide the details of the team/service/person you are complaining about
Name of service*
Address (Line 1)*
Address (Line 2)
City*
County*
Postcode*
Staff members involved*

Summary of complaint