We are very pleased to welcome Dr Marie Dawson who recently joined our team of GPs. Marie studied Medicine at Cardiff University in Wales and then qualified as a GP from the Ballinsasloe Specialist Training Programme in General Practice. She has a broad range of hospital experience and has a special interest in Women’s Health. As well as routine women’t health including cervical smears and ante natal care she offers long acting contraception device insertion.

COMPLAINT FORM

Patient Full Name:

Date of Birth:

Address:

Complaint details: (Include dates, times, and names of practice personnel, if known)

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SIGNED………………………………….          Print Name…………………………………..   Date………………………. (Continue overleaf if necessary)

 Office Use Only

Date Complaint In ………………………………         Clinician Involved…………………………………….

PATIENT THIRD-PARTY CONSENT

PATIENT’S NAME: ______________________________________________

TELEPHONE NUMBER: ______________________________________________

ADDRESS: ______________________________________________ ______________________________________________

ENQUIRER / COMPLAINANT NAME: _______________________________________ TELEPHONE NUMBER: ______________________________________________

ADDRESS: ______________________________________________ ______________________________________________

IF YOU ARE COMPLAINING ON BEHALF OF A PATIENT OR YOUR COMPLAINT OR ENQUIRY INVOLVES THE MEDICAL CARE OF A PATIENT THEN THE CONSENT OF THE PATIENT WILL BE REQUIRED. PLEASE OBTAIN THE PATIENT’S SIGNED CONSENT BELOW.

I fully consent to my Doctor releasing information to, and discussing my care and medical records with the person named above in relation to this complaint only, and I wish this person to complain on my behalf.

This authority is for an indefinite period / for a limited period only (delete as appropriate) Where a limited period applies, this authority is valid until…………………….. (Insert date)

Signed: ………………………………………. (Patient only)

Date: …………………………………………..