Online Complaints Form

Please fill in our complaints form with as much detail as possible.

If you are complaining on behalf of a patient we may contact you to provide us with written consent for you to act on their behalf.

If this form does not work - please try on a different web browser if you are able or alternatively please email admin.shp@nhs.net.

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Your Title and Full Name

Date of Birth

Your Address

Your Email Address

Your Telephone Contact Number/s

What is the best method to contact you?

Letter

Telephone

Is this complaint about

Yourself

On behalf of someone else

Making a complaint on behalf of another person

Please note that we will require signed consent of the patient for you to act on their behalf before we can investigate a complaint. If the patient is unable to provide their consent, please explain why in the relevant box below

Name of Patient

Their Date of Birth

Their address

What is your relationship to the patient?

Why is the patient not making the complaint?

Is the patient able to give signed consent?

Yes

If "No" please explain why

When did the main issue/event occur?

Who was involved? Please provide details of any other people who were involved or witnessed the event/s you are complaining about. Please provide the names/roles of any practice staff who were involved

What happened? Please describe the vents in the order they occured. if you have a specific question for the practice to investigatge and respond to, please list these in order of importance from the most important first

What was the impact of this/these event/s? How have you / the patient been affected?

What do you think should be done to put this right or to avoid it happening again?

What outcome are you hoping to achieve from making this complaint?

Any other comments or additional information