Complaint Form

Complaint Form

Complaint about a practitioner on the Acupuncture Society register
This information is needed for us to investigate your complaint about a registered practitioner’s Fitness to Practise.You can read our complaints procedure online at http://www.acupuncturesociety.org.uk/disciplinary-procedures/ so that you can understand our complaints procedures.
Please enter your contact details
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Daytime tel no.

Area CodePhone Number
Mobile No.

Area CodePhone Number
E-mail
The person you are complaining about

Please provide information to identify them on our register
Name

First NameLast Name
Complimentary therapy practised
Clinic Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please describe what you think happened
Did anyone else see what happened? If so, please give us their contact details.
Other Organisations
Have you reported this matter to anybody else (eg police, the persons employer, another professional body) If so, what was their response?
Please give us their contact details. Please keep us informed of any progress with the matter you have reported and let us know the final decision.
Name

First NameLast Name
Contact Number

Area CodePhone Number
E-mail
Please attach below any documents that you are sending us with this form.

Upload documents

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Please also use the space to provide us with any additional information that might help us to deal with this matter.
When and where did this incident take place?
The matter you are complaining about
Additional Information
When you have completed and submitted this form you will recieve and email copy, please print, sign and send it in hard copy to:

Practitioner Complaints Officer, Acupuncture Society, 27 Cavendish Drive. Edwgare, Middx. HA8 7NR

We acknowledge receipt of your complaint and will keep you informed about any progress regarding your complaint.
Date

MonthDayYear
Please sign here on your hard copy
Should be Empty:

Complaint Form

Please enter your contact details

The person you are complaining about

Other Organisations

Additional Information