Concerns and complaints form :: Surrey and Sussex Healthcare NHS Trust

Please complete the fields below to let us know how we can help you. Required

Appointments - are you expecting or are you concerned about a forthcoming appointment?

Admission - do you need information or support with an approaching admission to hospital?

Inpatients - do you have a friend or relative on one of our wards who needs some support?

Assistance - is there something that we can do to ensure that your visit to hospital goes smoothly?

Do you want to make a complaint? Please use this option if you feel something has happened that needs to be investigated by the Trust Complaints team. If your complaint concerns a relative, please include their full name, address, and date of birth.

Reporter

Title

Miss

Mrs

First name

Surname

Your date of birth

Address

Address 1

Address 2

City

Country

County

Postal Code

Email address

Phone number

Your NHS number

Your MRN (hospital) number

Are you filing a report about a patient other than yourself?

Yes

Please note: Patient's consent is required whenever a complaint/concern relates to the treatment received by the patient and the person raising the complaint/concern is not the patient.

The consent needs to be obtained before confidential or information of a sensitive nature is released to a third party.

We will acknowledge your complaint/concern and send you a consent form to be signed by the patient involved.

Please fill in as many patient’s details as possible.

Patient's details (if different from reporter)

Patient first name

Patient surname

Patient date of birth

Patient's address

Address 1

Address 2

City

Country

County

Postal Code

Patient email address

Patient phone number

Patient NHS number

Patient MRN (hospital) number

Report details

Location/department in the Trust to which the report relates

Please enter the date of the event or incident which has prompted you to report a concern or complaint.

Please give us a description of what has gone wrong and how we can help.

It may help us if you can give us the names of any staff involved

I agree to the privacy policy

Concerns and complaints form

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Reporter

Patient's details (if different from reporter)

Report details

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Concerns and complaints form

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Reporter

Patient's details (if different from reporter)

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