Complaints Form

If you wish to make a complaint to the practice please complete the following form. You complaint will be dealt with following the practice complaints procedure.

Patient Details

Patients Name

Patients Date of Birth

Patients Address

Patients Telephone Number

Patients Email Address

Who is Making the Complaint

Are you making this complaint on behalf of someone else?

Yes - please complete Representative details

No - Please go to Details of your complaint

Representative Details

Your Name

Relationship to Patient

Your telephone number

Your email address

Do you have the patients consent to act on their behalf?

Yes

Details of Your Complaint

Date of the incident

Where did this happen? e.g in the practice, over the phone

Who was involved? (if known)

Please describe what happened:

How has this affected you or the patient?

What outcome are you hoping for?

Explanation / apology

Review of care or service

Changes to prevent recurrence

Other

If Other please specify

Have you raised this issue before?

Yes

If yes please provide details

What happens next?

• We will acknowledge your complaint within 3 working days.

• We aim to provide a full response within 40 working days.

Data Protection Notice

Your information will be handled confidentially and in accordance with UK GDPR and NHS data protection requirements. Information will only be shared where necessary to investigate your complaint.

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Solent View Medical Practice • Lee-on-the-Solent Health Centre, Manor Way, Lee-on-the-Solent, Hampshire, PO13 9JG.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.