Complaints Form We are sorry to hear that you have felt that you need to make a complaint. In order for the surgery Team to deal with your complaint we would appreciate it if you are able to take the time to complete this form. This will allow us to determine what has gone wrong and why and allow a focused response to you in a timely manner. Please answer the following questions as concisely as possible in the spaces provided Personal DetailsYour Name First Name Surname Email Address Optional Contact Number OptionalYour Complaint1. Please describe in one or two sentences the issues that have led you to this complaint2. Has this problem occurred previously?3. 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 etc4. 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.5. Are you happy for us to review things going forward? Yes No 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.
