Hindhayes Lane, Street, Somerset, BA16 0ET

Tel: 01458 84 11 22

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COMPLIMENTS, CONCERNS, OR COMMENTS

Please use this form for compliments, concerns and comments only.If you have a personal or other clinical query please contact reception and arrange an appointment or a telephone consultation with a doctor or nurse.

Personal Details

Name: Date of Birth: Address: Postcode: Daytime Telephone Number: Mobile Telephone Number: Email Address:

Concern / Comment / Compliment

My query relates to:

Patient Details (if different to above)

Name of Patient: Date of Birth: Address: Postcode: Daytime Telephone Number: Mobile Telephone Number: Email Address:

Service

Type of Service: Name of Service: Address of Service:

Details of the event

The event raises either a concern, comment or compliment

What would you like to happen as an outcome

My ideal outcome would be

Confirm your Location

I confirm that I am a patient at Vine Surgery, Street, Somerset.

Information provided by you through this form will allow us to improve our services. The form data undergoes encryption during transmission and while at rest, and will only be retained for a duration sufficient to process your request. You have the option to withdraw your request at any time by notifying the practice. By using this form you are agreeing to our privacy guidelines.

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