Complaints Form

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All questions marked with a * are mandatory

Are you contacting the practice on behalf of someone else?: *
Details of Person Completing Form

Giffords Surgery is strict with the rules of confidentiality. If you are contacting the practice on behalf of someone else, we will request consent from patient for you to do so.

Please read and agree to the below statement which will allow us permission to speak with the person detailed below on your behalf.

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Patient Details
Please double check you've entered the correct email address
if known
May be used to identify you
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Complaint Details
Has this happened before?: *
Can you identify where the issue may have arisen?: *
Would you like to raise a formal complaint to Giffords Surgery?: *

Privacy Consent

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