Complaints Form

    NOTE: This form is not to be used for a complaint on behalf of someone else. For a complaint on behalf of someone else please click here to download a form that includes third party consent. We need this consent in order for us to discuss the complaint.

    * Star is to show which boxes must be completed.

    Please send report marked: PERSONAL IN CONFIDENCE

    Which surgery are you a patient of?:

    Swan Surgery PetersfieldLiphook Village SurgeryLiphook Station Road SurgeryLiss Hillbrow SurgeryRiverside Kelsey Surgery

    Complainant’s Details

    Address

    Preferred means of contact:

    Patient’s Details

    (if different from above)

    Address

    Full Details of Complaint

    Date/time problem arose:

    Date reported to Practice:

    Place:

    Identify member(s) of practice involved:

    Full description of events (i.e. the facts surrounding circumstances giving rise to your complaint, please continue on a separate sheet if required):

    Complainant’s signature