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Complainant’s details

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Patient's Details (if different from page 1)
Your Complaint

Full details of the complaint

Please include member(s) of practice involved and full description of events (i.e. the facts and surrounding circumstances giving rise to your complaint):

Where the complainant is not the patient

I hereby authorise the above complaint to be made. I also agree to disclose confidential medical information about me to the person named below. This information should only be in relation to the complaint.

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.


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