COMPLAINT FORM

Complaint Form

  • Details of Individual making Complaint:

  • Patient’s Details (if different from above, see also Third Party Consent form below)

  • Full Details of Complaint:

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Southern Hampshire Primary Care Alliance - CONSENT FORM

    I confirm that I accept that Southern Hampshire Primary Care Alliance will process my complaint and that Southern Hampshire Primary Care Alliance will only forward a copy of my complaint to organisation(s) for direct investigation after gaining consent from me. I also confirm that I accept that a copy of all correspondence will be held by the Southern Hampshire primary Care Alliance. I consent, to the release of my health records to the Southern Hampshire Primary Care Alliance and understand that the information obtained will be used to assist in the investigation of my complaint. Confidential information can and may be shared with the following organisations: The Complainants GP Practice
  • Date Format: MM slash DD slash YYYY
  • Any information is retained in accordance with the Alliance’s retention schedule and Department of Health guidance.
  • Please complete and return this form within the next fourteen days to:

    Email: shpca.complaintsincidents@nhs.net

35, Pure Offices
One Port Way
Port Solent
Portsmouth
PO6 4TY

Contact Us

Tel: 02392 414020
Email: shpca.info@nhs.net