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Compliments and complaints form

Section 1a: Your details*
First we need some general information about you:

Street Address Town/City County Postcode
Are you the Patient / Client affected ?*
- Yes
- No
Section 1b: Your details continued
The information in this section will help us manage your compliment or complaint more effectively
Date of Birth*

DD
MM
YYYY
Hospital Number (if known)
Telephone number
If you are leaving a compliment or complaint on your own behalf
Section 2: Details of the patient or client affected
If you are leaving a compliment or complaint on behalf of someone else, please give us their details:
Name
First Last
Address*
Street Address Town/City County Postcode
Date of Birth*

DD
MM
YYYY
Hospital Number (if known)
Telephone
Your compliment or complaint
You may not be able to complete all these fields, but the more information you can give us will help us direct your comments to the right area or department.
Exact location the compliment or complaint relates to:
Staff member(s) involved:
Date of incident*
Date Format: DD slash MM slash YYYY
Describe your compliment or complaint:*
Email
Enter an email address to receive a confirmation
Enter Email Confirm Email
Patient Consent
Anyone who uses any of our services can leave a compliment or complaint. You can also leave a compliment or complaint on someone else’s behalf, although you will generally need their written consent for complaints.

Please note, that to enable us to investigate your complaint, your personal information (eg. relevant health or social care records) may need to be available to the person/s investigating your complaint.

If you have any concerns about this, please contact our Complaints Department staff.

Please see the privacy statement for more information about how we use your information
Name
This field is for validation purposes and should be left unchanged.

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Contents

Compliments and complaints form

Section 1b: Your details continued

Section 2: Details of the patient or client affected

Your compliment or complaint

Patient Consent