Title: Form A
Author: EMIS_1637pa
Last saved by: Practice Aministrator
Company: Barnsley PCT

Form A (staff to ensure that the patient is given the complaints leaflet)

To be given to the patient making the complaint. Can be used by someone acting on behalf on another patient, provided the consent form B is signed and attached to this form A

This address will be where the Practice will send ANY correspondence regarding the complaint unless you state otherwise
Name

Address
Line1
Line 2
Line 3

Post code

Telephone number (s)
Home
Mobile

Date of Birth

Please use this section for details of the complaint
(Please ask the receptionist for further blank pages if required)

DETAILS OF YOUR COMPLAINT
(Please help us if you can by trying to remember any relevant dates or names of staff.)

Please make use of the blank sheet attached

Appendix 3

Form B (staff to ensure that the patient is given the complaints leaflet)

To be given to the person who may be too ill or incapable of making the complaint themselves.

I authorise (Insert name of the person who is acting on your behalf)

……………………………………………………………………………………………………………………………….

To act on my behalf and I agree that the practice may disclose to my chosen authorised person any confidential details that may be necessary to answer the complaint

Now insert your own name & your own date of birth

Print Name……………………………………………………………….DOB………………………………………..

Please supply your signature

Signature……………………………………………………………

Form A & B should be attached and submitted together