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["PATIENT COMPLAINT FORM"]
["Please note that we can only investigate complaints with patient consent. If you are completing this form on behalf of an adult, we require their consent to proceed."]
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["Your Details "]
["Name:"]
["DOB:"]
["Address:"]
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["Summary of Complaint "]
["Please describe the events leading to your complaint to help us understand your experience"]
["Please tell us (in your own words) why you think these events occurred?"]
{"$rows_empty":8}
["Have you experienced this issue before?"]
["..either at this surgery or at another healthcare provider. Please provide details if it was previously resolved."]
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["Can you help us understand what you think should have happened?"]
{"$rows_empty":7}
["Please tell us what you want to achieve from this complaint? "]
["Common outcomes from complaints include improving our service through training, saying sorry when we have made a mistake, addressing a communication problem or exploring the issues with you in more detail."]
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["Next steps and what you can expect from us"]
["We would like to review this information as part of our ongoing commitment to improving our services. We would hope to reach a positive outcome for you and the practice and ensure that our systems are as effecvie as we can make them."]
["Would you like us to review this feedback going forward as part of our learning    ",{"$nulls":6},"YES","NO"]
["Would you like us to arrange a face-to-face meeting with you and a GP or Practice Manager ",{"$nulls":6},"YES","NO"]
["(please circle) "]
["Please sign to indicate your consent "]
["If you are completing this for somebody else, please write your name"]
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["Please send this form to:",null,null,"complaints@branstonsurgery.com"]