Feedback

At Kennet and Avon Medical Partnership we strive to deliver the best quality patient care at all times and in all areas of contact with the patient or patient’s representative. There may be times when you feel very happy with our service, or you are less than happy with the service you have received. Your comments whether positive or negative can help us to improve the service we offer.

If you have a compliment, complaint, concern or simply some feedback about the service you have received from any of the staff working in the practice, or the practice itself, please let us know by completing this form and returning it to the Practice Manager.

For more information, please review our Complaints Policy.

Feedback

Feedback

If you are human, leave this field blank.

I would like to register: *

A Compliment

Piece of Feedback

Concern

Complaint

The service involved a: *

GP

Practice Nurse

Other Staff Member

Please state: *

It concerns: *

Administration

Attitude

Cleanliness of Facility

Convenience of Appointment

Quality of Care by the Practice

Other

Please state: *

Full Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

Phone Number:

Email Address: *

Address:

Your Feedback: *

Would you like your feedback to be treated as a formal complaint? *

Yes

No

If known, please give the relevant date/s in regards to your above complaint: *

Please use the format DD/MM/YYYY

Are you completing this form on behalf of someone else? *

Yes

No

Full name of complainant: *

Your relationship to complainant: *

Complainant's Date of Birth: *

Please use this date format: DD/MM/YYYY.

Complainant's Telephone Number: *

Complainant's Address: *

If you are complaining on behalf of a patient or your complaint involves the medical care of a patient then we will require the signed consent of the patient in order to progress the complaint. Therefore, please obtain the patient’s signed consent below.

I fully consent to my Doctor releasing information to, and discussing my care and medical records with the person named about in relation to this complaint, and I wish this person to complain on my behalf.

Patient Signature: *

Date: *

*

I confirm that if I am making a formal complaint, the practice needs all of the above personal details.

(Full name, Date of Birth, Address & either phone number or email address)

*

I confirm that my enquiry is not urgent, and it may take up to 5 working days before I receive a reply.