Complaints Form The Thornton Practice Complaint Form In order for the practice to be able to address your concerns or complaint please complete the form to assist our team. I am making this complaint on behalf of Myself Someone Else Patient DetailsName First Last Date of Birth DD slash MM slash YYYY Address Street Address Address Line 2 City Post Code PhoneEmail Complaint DetailsStaff Member Name / or Team (if applicable):Date of Incident DD slash MM slash YYYY Reason(s) for Complaint. Please tick all that apply and provide details below Difficulty accessing the service / booking an appointment Long waiting times Inappropriate treatment or advice Misdiagnosis or delayed diagnosis Staff rudeness or unprofessionalism Lack of communication or poor explanation Breach of confidentiality Other – Please Specify Description of the Complaint (please describe the issue in detail, including what happened, when, and any individuals involved): Desired Outcome. Please tick all that apply: An explanation and/or apology A review of policies or procedures to prevent recurrence Reassessment or second opinion on treatment Disciplinary action (if appropriate) Other – Please specify Please provide further informationDeclaration I confirm that the information provided in this complaint is accurate to the best of my knowledge.SignatureDate DD slash MM slash YYYY Third Party Declaration: I hereby authorise the individual detailed below to act on my behalf in making this complaint and to receive such information as may be considered relevant to the complaint. I understand that any information given about me is limited to that which is relevant to the subsequent investigation of the complaint and may only be disclosed to those people who have consented to act on my behalf.This authority is for an indefinite period a limited period only Where a limited period applies, this authority is valid until DD slash MM slash YYYY SignatureDate DD slash MM slash YYYY Name First Last Address Street Address Address Line 2 City Post Code Date of Birth DD slash MM slash YYYY Phone
