Comments & Complaints Form Are you completing this form for yourself or on behalf of someone else? For myself On behalf of someone else Complaining on Behalf of Someone Else We keep to the strict rules of medical and personal confidentiality. If you wish to make a complaint and are not the patient involved, we will require the written consent of the patient to confirm that they are unhappy with their treatment and that we can deal with someone else about their concerns. Name First Last Date of Birth Day Month Year PhoneEmail Enter Email Confirm Email SubjectComplaint DescriptionFile OptionalMax. file size: 50 MB.