Complaints form

National Institute of Medical Herbalists

Complaint and declaration form

Our Complaints and Disciplinary Procedures explain how we deal with complaints. If you wish to make a formal complaint against an Institute member after you have read the procedures, please complete this form.

PART 1: YOUR DETAILS

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Phone Number

Area CodePhone Number

Who are you raising this complaint for?

YourselfSomeone else (please give the patient name below)

Patient name if not your own

If your are raising this complaint for someone else please confirm that:

The patient is aware you are raising the complaintThe patient has given you their consent to do so

And state your relationship to the patient:

Is your/the patient's care from the subject of the complaint still ongoing?

YesNo

PART 2 - HERBALIST DETAILS

Name of the medical herbalist you are complaining about:

Practice address

Date of first consultation

Date

Number of consultations

Number of repeat prescriptions

PART 3 - COMPLAINT DETAILS

Please describe the complaint explaining what happened, where and when. Please include any papers or documents that support your complaint and indicate if there were any witnesses to any incidents you have described. You should not send us information that you are not prepared to share with the medical herbalist you are complaining about.

Upload any supporting documents here

Browse Files

Have you raised this complaint with the herbalist concerned or a member of their practice?

YesNo

Please provide details below of what happened OR why you have not raised the complaint directly:

I give consent for the Institute to investigate and deal with my complaint. I understand that my name and complaint will be passed to the medical herbalist I am complaining about. I agree to the medical herbalist seeing my complaint.

I give permission for my patient records and reports to be passed to the Institute to help investigate my complaint.

By selecting ‘Yes’ below I declare that the information I have given is correct and accurate, and that, if I am making this complaint on behalf of another person, they know the complaint is being made, they know the procedures that will be followed and that they give their full permission.

Yes, I confirm this declaration

National Institute of Medical Herbalists 2020

Declaration