Complaint Form JCP

Your Details

Patient Name *

Address *

Date of Birth *

Telephone Number *

Email Address

Details of the person making the complaint, if not the above

If you are raising a complaint on behalf of another individual, we will need to obtain their consent, where necessary, for you to do so.

Name

Date of Birth

Telephone Number

Email Address

Address

Complaint

Details of Your Complaint *

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 19 May 2026
Page created: 03 November 2026

Cookies on the The James Cochrane Practice website

Complaint Form JCP

Further Information