SQUIRES LANE MEDICAL PRACTICE
Dr. E. Barthes-Wilson, Dr G Thawani
2 Squires Lane, Finchley, London N3 2AU   Tel: 020 8346 1516  Fax: 020 8343 2537

COMPLAINT FORM

Squires Lane Medical Practice
2 Squires Lane
London
N3 2AU

OF IF THE COMPLAINT IS ABOUT THE PRACTICE MANAGER, PLEASE ADDRESS YOUR COMPLAINT TO DR BARTHES–WILSON & DR THAWANI AT THE SAME ADDRESS. 

Name of patient experiencing problem: ……………………………………………………

Date reported to practice: ………………………………………………………………….

Date of incident / problem: ………………………………………………………………...

Address of patient: ………………………………….. ……………………………………
			
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Name of person reporting problem if different to above: 

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Address: ……………………………………………………………………………………

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Nature / description of grievance: …………………………………………………………

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(Continue over leaf if necessary)

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Signature of patient