Patient_Comments_Form_PMC

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					                                                                                    Parkgate Medical Centre
                                                                                           Netherfield Lane
                                                                                                  Parkgate
                                                                                                Rotherham
                                                                                                  S62 6AW

                                                                                      Tel:   01709 514 501
                                                                                      Fax:   01709 514 490


                                          Patient Comments Form

                                 Personal Details (of person making comment)


Name :…………………………..…………………………….. Date of Birth …………………………….

Address: ………………………………………………………………………………………….………....

………………………………………………………………………………………………..………………

Postcode: ………………………………Tel No: .………………………….……………………………..

                                       Patient Details: (if different from above)

Name :…………………………..…………………………….. Date of Birth …………………………….

Address: ………………………………………………………………………………………….………....

………………………………………………………………………………………………..………………

Postcode: ………………………………Tel No: .………………………….……………………………..

Details of the comment, compliment or complaint:
(Please continue on a separate sheet if necessary)




I hereby authorise the above comments to be made. I agree that members of the practice staff may disclose
in so far as necessary, confidential information about me, which I have provided to them.

Signature: ……………………………….…………………………… Date: ……….…………………………………
(If you are not the patient, please ask the patient of parent/guardian to sign)

This does not affect your statutory rights to make a formal complaint to the Health Authority or to seek
independent advice. If you wish to complain to the Health Authority, you must do so within 13 weeks of the
event.



\Forms\Patient Comments Form A4..doc

				
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