Complaint form – Rivermead Gate Medical Centre

Name:*
First Last
Address:*
Daytime telephone number*
Email address:*
Enter Email Confirm Email
Complaint details: (Include dates, times, and names of practice personnel, if known)*
Please note: If you are not the patient we will require written consent from the patient to communicate with you. You will need to complete a third party consent form available from the practice.
Consent*
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
I agree to the privacy policy.