Complaint Form - Blackmore Vale Partnership

This form is for non-urgent or non-clinical correspondence. If you require assistance from a clinician or help with a prescription please visit SystmConnect.

Complainant's Details

Name

First Last

Enter Email Confirm Email

Date of Birth

Are you making the complaint on behalf of another patient

Yes

Patient's Details

Name

First Last

Date

Your relationship with the patient

Formal Complaint Details

Please describe in as much details as possible the clear details of your complaint

ie: The main issue with the medical advice/treatment/service you have received and exact details what happened including any dates, times, who was involved

Please advise us if you have any additional supporting documentation or evidence that you would like to provide that you think may be helpful with the investigation of your compliant.

Upload Images/Documents Optional

Drop files here or

Accepted file types: doc, docx, pdf, jpg, png, Max. file size: 1 GB, Max. files: 5.

Please kindly describe how this situation has affected you/others?

Please describe what you feel the practice should do to help try and resolve this issue going forwards?

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data

Consent Declaration

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