Suggestions and Complaints at Tudor Lodge Surgery

Leave a compliment

Name^*

We understand that you may wish to submit your feedback anonymously - by doing so it will be impossible for us to investigate any issues that you may raise thoroughly, so please leave your name and contact details so that we can investigate your issues and give you a response.

Date of Birth

Who would you like to leave this feedback about?^*

Date & Time

Your feedback*:

How would you rate your experience?

Make a complaint

Name^*

Date of Birth

Are you the patient involved in this complaint or are you making a complaint on behalf of someone else?^*

I am the patient I am not the patient

Do you have the consent of the patient involved to make this complaint on their behalf?^*

I do have the consent of the patient involved to make this complaint I do not have the consent of the patient involved to make this complaint

Do you know the name(s) of the staff involved?^*

Date & Time

What is the issue?*:

What would you like to happen to resolve this issue?:

Suggestions & Complaints

Leave a compliment

Make a complaint

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