Concerns and complaints form

Section 1: your details

Title e.g. Mr, Mrs, Miss, Dr etc.

First name

Surname

Date of birth

Your address

Daytime contact telephone number

Mobile telephone number

Email address

How would you prefer us to contact you?*

Section 2: if you are making the complaint on behalf of someone else, please enter their details in this section

Title e.g. Mr, Mrs, Miss, Dr etc.

First name

Surname

Date of birth

Address

Your relationship to the patient

Daytime contact telephone number

Mobile telephone number

Email address

Section 3: about your concern or complaint

Are you contacting us about a concern or a complaint?

Please give the name of the organisation, service or person your concern or complaint relates to

In the box below, please explain why you want to complain and give as much detail as possible. The following questions may help you; what happened, who was involved, what was said, where and when did it take place? (please give dates and times if possible), why do you think the service failed?

What outcome would you like in response to help resolve your concern or complaint?

Click the button below to submit your complaint. This form will be sent to the Patient Support Line at Bradford Districts and Bradford City Clinical Commissioning Groups (if you have given your consent).

Email 2*:

* required fields

 

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