Hospital Complaint Record Date received: ____ 1 _____ Received by:____ 2 _________ How received: £ £ visit £ £ phone £ £ letter £ ___3______ Patient details Full Name:______ 4 _______ Tel:_______ _5 _______ Address: ____ 6 __________ Hospital details Name:_____ _7 ________ Tel:_______ 8 _____ Address: ___ 9 _______ Nature of complaint (reason for dissatisfaction): (1) ______________ 10 ________________ (2) ______________ 10 _________________ Solution (action) Required: (1) ___________ _11 _________________ (2) ____________ 11 ___________________