Complaints Form - Eltham Palace PMS

Please read our Complaints Procedure before completing this form

Are you completing this form on behalf of someone else?

No, I am the patient

Yes, on behalf of someone else

Patient's Full Name

First Last

Patient's Date of Birth

Please use the format Day/Month/Year e.g. 13/01/1970

Patient's Telephone Number

Patient's Address

Your full name (the person completing the form)

Your email address (the person completing the form)

Your Phone Number (the person completing the form)

Please give the full details of the complaint below, including dates, times, locations and names of any organisation and/or staff (if known).

Confirmation

I understand the practice complaints procedure and timelines to be followed

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.

Consent

I consent to the Practice collecting and storing my data from this form.