If you need any help to complete this form you can contact us on 01274 237562.

Section 1: Details of the patient involved in the complaint.

If you are making the complaint on behalf of a friend or family member, please complete section 2.

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

First name (required)

Surname (required)

Date of birth (dd/mm/yy) (required)

Address (required)

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 a friend or family member, please complete this section.

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

First name

Surname

Date of birth (dd/mm/yy)

Address

Your relationship to the patient

Daytime contact telephone number

Mobile telephone number

Email address

Section 3: About your complaint

Please give the name of the organisation, service or person you are complaining about

In the box below, please explain why you want to complain and give as much detail as possible. The questions below may help you:
• What happened?
• Who was involved?
• What was said?
• Where and when did this take place? (please tell us dates and times if at all possible)
• Why do you think the service failed?

What outcome you would like in response to your complaint?

an apologyan explanationimprovements or changes madeother (please specify below)

Please note, when dealing with complaints we cannot:
• have a member of staff disciplined
• give any legal advice
• help with complaints about private medical treatment.

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Click the button below to submit your complaint. This form will be sent to NHS Airedale, Wharfedale and Craven Clinical Commissioning Group.