Complaint Form

1. Your Details

Your Name

Your Address-Insert Your Address-

Your Postcode

Your Date Of Birth

Your Home Telephone Number

Your Daytime Telephone Number

Your Email Address

If you are complaining on behalf of someone else, you must complete section 2, if not, go to section 3.

2. Complaining on behalf of someone else.

ONLY complete this section if you are making a complaint on behalf of someone.

I am making this complaint on behalf of:

Name

Address-Insert Address-

Postcode

Home Telephone Number

Daytime Telephone Number

Email Address

What is your relationship to the person who has the complaint?

Please explain why the person is not making the complaint?

3. Which dental organisation and/or practitioner are you complaining about?

Give the names

Have you complained to the organisation
or practitioner?Yes   No

If yes, please give names and, if possible, job titles of whom you contacted

Was your complaint made in writing?Yes   No

Have you received a reply?Yes   No

Have you contacted anyone else
about your complaint?Yes   No

If yes, please say who and what the outcome was:

4. What are you complaining about?

Describe the complaint

5. What do you want the Dental Complaints Service to do?

Describe the action to be taken

6. Have you taken, or are you planning to take, legal action?

Yes   No
(If yes, this may affect our ability to consider your complaint - please call our helpline)

7. How did you find out about the Dental Complaints Service?

Choose from the following list Please SelectCitizens Advice BureauHealthcare CommissionOther advice serviceDental SurgeryHospitalDoctor's SurgeryNHS OrganisationFriend or RelativeGovernment DepartmentMember of Parliament (MP)LibraryNewspaperRadio or TVInternet WebsitePhone bookDirectory EnquiriesOther - please give details