Online Complaints Form Patient Name First Last Address Street Address Address Line 2 City Postcode Telephone No.Please describe in one or two sentences the issues that have led to this complaint. This will help us understand the key problems that you have experienced.Has this problem occurred previously? Yes No Please can you identify where the issue may have arisen? For example, did this happen as a result of conflicting messages, a personality conflict, a problem with communication within the surgery, etc.Are you looking for a specific outcome from this complaint? Common outcomes that help us improve our service include training, improved communication, looking at ways to work differently, or by simply apologising where your experience has not been as you had wished.We would like to review this complaint as part of our complaints procedure to ensure our systems are as efficient as we can make them. Are you happy for us to review things going forward?Patient Third Party ConsentEnquirer / Complaintant Name First Optional Last Optional Address Street Address Optional Address Line 2 Optional City Optional Postcode Optional Telephone no.If you are complaining on behalf of a patient or your complaint or enquiry involves the medical care of a patient then the consent of the patient will be required. Please obtain the patient’s signed consent below. I fully consent to my Doctor releasing information to, and discussing my care and medical records with the person named above in relation to this complaint only, and I wish this person to complain on my behalf. This authority is for an indefinite period / for a limited period only (delete as appropriate)Where a limited period applies, this authority is valid until Optional MM slash DD slash YYYY Date Optional MM slash DD slash YYYY