Complaint Form

Last Updated: 22/04/2025

Your Details

Name *

Date of Birth *

Phone Number

Email Address *

Complaint

Which service is this complaint regarding *

GP Surgery

Community Dermatology

Community ENT

Please let us know which branch this is regarding. *

Great Holm

Shenley Church End

Stony Stratford

Your Complaint *

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. *

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

By checking this box you are accepting this as acknowledgement of your complaint, we will investigate the points you have raised and get back to you with an explanation. There are no timescales for providing a response, but we aim to get back to you within 30 working days, if this is not feasible you will be updated, and informed of the reasons for the time taken, in writing if there is no response provided within six months. *

I accept this as acknowledgement of my complaint.

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