Complaint Form | Bevan Group Practice

This form is only to be used for complaints.

Anything other than complaints will not be actioned.

Complaint Form

Date *

Name *

Date of Birth *

Contact Number *

Address *

Complainant (written consent is needed from any patient over 18yrs if someone is complaining on their behalf)

The Patient

The Patients Relative/Representative

Name of complainant if not the patient

Date of Incident *

Complaint (please give as much detail as you can) *

Has this happened previously? *

How would you like this to be resolved? *

If you are human, leave this field blank.