Complaint Form Page 2

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4. Is there anything else that you want to tell us?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
5. What do you want to happen as a result of this complaint?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
If you are complaining on behalf of someone else?
Please give the details of the person the complaint is regarding:
Name:
__________________________________
Address: __________________________________
__________________________________
__________________________________
Please state your relationship to this person: _________________________________
Is this person aware that you are complaining on his/her behalf? YES
NO
Is someone representing you?
(e.g. solicitor or advocate)
YES
NO
If yes please give us the details of your representative
Name: ____________________________________
Organisation: _______________________________
Telephone: ____________________
Postal address: _____________________________
______________________________
______________________________
Tahunanui Medical Centre – Complaint Form September 2012
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