MediWell Clinic

Patient Complaint Form

Please Note: All complaints should normally be made within 12 months of the date of the event complained about. The time limit can be waived if you give good reasons for missing it and the complaints manager decides a fair investigation is possible.

Patients Full Name

Date of Birth

Address

Phone Number

Date of Visit

Your Complaint

If you are submitting a complaint on behalf of someone else, we need to know that you have their permission to do so in order to ensure we maintain patient confidentiality. If you've their permission please put your name below.

Complaint Submitted by