Complaint Form

Complaint Form
Your Name*

First NameLast Name
Email*
example@example.com
Gender*

MaleFemaleOther
Date of Birth

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (00000) 000000.
I am a*

A PatientWriting on behalf of a patientA member of the publicAn AcupuncturistAnother medical professionalOther
Your Complaint
Individual*

First NameLast Name
Clinic Address*

Street Address

Street Address Line 2

CityCounty

PostCode
Date of Incident*

MonthDayYear
Date
Location of Incident*
Please explain what happened*
Did any other people see or hear the things you are complaining about?*

YesNo
Please give their names and contact details if possible and explain how they were involved*
Do you have any documents (e.g., letters) that might support your claim?*

YesNo
If yes, then please give details*
Have you already complained to anyone else about this matter? e.g. the individual? the clinic?*

YesNo
If yes, then please give details*
Should be Empty:

Your Complaint