Patient details:

Title:*

MrMrsMissMsDoctorOther

First name:*

Last name:*

Postal address including postcode:*

Contact number:

Email address:

Date of birth:

NHS number (if known):

Your details (if you are not the patient):

Title:

MrMrsMissMsDoctorOther

First name:

Last name:

Postal address including postcode:

Contact number:

Email address:

What relationship are you to the patient?

Spouse

Partner

Parent

Guardian

Other

Which site did the issue take place:*

York HospitalScarborough HospitalBridlington HospitalSt Monica's EasingwoldMalton HospitalWhite Cross CourtThe New Selby War Memorial HospitalOther - please state in your summary

Which ward did the issue take place:

Date the issue took place:*

Please summarise the issue that has led to you to make your complaint:*

Any additional information:

What would you like to happen as a result of your complaint? Please note that if we do not think that we can achieve what you want, we will let you know.

Apology

Explanation/information

Change in procedure

Prevent others having a similar experience

Other (please specify below)

Other:

The information I have provided is accurate to the best of my knowledge.*