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Shah Zaman Surgery NHS GP Surgery

Complaints form

Complaints

Section

Preferred method of contact *

Phone

Preferred time: *

Morning

Afternoon

If you are not the patient, has consent been obtained? *

Yes

N/A

Patient Consent

If you are acting on behalf of a patient, then the consent of that patient will be required. Please obtain the patient’s signed consent below.

Patient confirmation *

I fully consent to the practice 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.

Patient consent *

I give consent for an indefinite period

I give consent for a limited period only

Please enter the date when this consent should expire: *

For example, 31/3/1980

Patient signature *

Date