If you have any concerns, complaints, or feedback about the services we provide in Bristol or Weston - please tell us by filling in this form.
We will always treat the information you send us with the strictest confidence and will not pass on any information to third parties.
Please note that there are some fields in this form which must be completed before you will be able to submit your enquiry. This will ensure that we have all the information we need to enable us to deal with your enquiry promptly.
If you are completing this form on behalf of someone else, we may require consent. If needed, we will ask for this when we acknowledge receipt of your enquiry.
Date form completed
Date of event (if appropriate)
Hospital/ward/department
Brief details of your complaint, concerns, or feedback (including names, dates and locations where appropriate)
First name
Surname
Your address
Telephone number
Email address
Your date of birth
Your hospital/NHS number (if known)
Are you raising this matter on behalf of someone else? If yes, please complete the additional questions below.
Name of patient
Address of patient
Relationship to patient (if relevant)
Telephone number of patient
Date of birth of patient
Hospital/NHS number of patient (if known)
Consultant/specialist of patient
I consent to having my information stored for the purpose of this online support/complaint form. I know you may need to contact me in relation to my form. I understand that if I don't consent I cannot submit online.