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									                                     COMPLAINTS WEB PAGE
                                    Patient Relations Department

                                          COMPLAINT FORM

If you need help completing this form, please ask a member of staff by contacting the Patient
Relations Department on (0113) 2066261; Minicom (0113) 2066018; or fax (0113) 2066146; or
e mail patient.relations@leedsth.nhs.uk

 Date of incident/event:                        Date complaint form completed:


 Name and Address of person making              Name and Address of patient (if different):
 complaint:




 Tel. No of complainant:                        Tel. No of patient (if relevant):


 Relationship to patient:                       Consultant/Specialist of patient:


 Hospital and Ward/Department:                  Ethnicity of patient:


 Unit No (if known):                            Date of birth of patient:


 If the person making the complaint is not the patient, we will require signed consent from the
 patient to take this forward on their behalf. If this is the case, when we have received this
 form, we will send you an acknowledgement letter and a consent form to be signed by the
 patient.


 In order for your formal complaint to be investigated, please complete the remainder of this
 form and then return it electronically to patient.relations@leedsth.nhs.uk - or you can send the
 form by post to:

                            The Patient Relations Manager,
                            Leeds Teaching Hospitals NHS Trust,
                            Trust Headquarters,
                            St James’s University Hospital,
                            Beckett Street,
                            Leeds    LS9 7TF
Please provide an account of the incident(s) leading to the complaint being made:




State the areas you would like investigated:




What outcome do you wish from this complaint:




     I:karen/complaintswebpage/complaintform – 7.2.07; 12.2.07; 1.2.08

								
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