Complaint Form
Your Name
*
First Name
Last Name
Email
*
example@example.com
Gender
*
Male
Female
Other
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
I am a
*
A Patient
Writing on behalf of a patient
A member of the public
An Acupuncturist
Another medical professional
Other
Your Complaint
Individual
*
First Name
Last Name
Clinic Address
*
Street Address
Street Address Line 2
City
County
PostCode
Date of Incident
*
-
Month
-
Day
Year
Date
Location of Incident
*
Please explain what happened
*
Did any other people see or hear the things you are complaining about?
*
Yes
No
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?
*
Yes
No
If yes, then please give details
*
Have you already complained to anyone else about this matter? e.g. the individual? the clinic?
*
Yes
No
If yes, then please give details
*
Send Complaint
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