Complaint Form
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1Practice Name or Logo
Complaint Form
Details of receipt of complaint
Date of complaint:
_______________________________
Time: __________________
Complaint Received By:
_________________________________________________________
Method by which complaint made:
Phone
in person
etter
mail
Details of the person making the complaint
Name:
____________________________________________________________________
Address:
____________________________________________________________________
____________________________________________________________________
Phone:
_________________ ____________
Mobile:
_____________________________
Details of complaint
Description of event/complaint
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Was an Incident form completed?
Date: ____________
Time: ___________
Practice Manager notified:
Date: ____________
Time: ___________
Complaint acknowledgement letter sent:
Date: ____________
Time: ___________
Outcome
What action was taken?
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________
Was placed in agenda for the next Practice meeting:
Was this matter satisfactorily resolved?
Was letter of outcome sent to person making complaint?
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Parent category: Legal