Complaint Form

Please complete the form below as fully as possible. If you need help with this please telephone us. You don’t need to fill it in to seek our help, you can telephone us on 094 902 5105.

 

Your Details

Your name
Your address
Town
County
Your home telephone number
Your daytime telephone number
Your email address

If you are complaining on behalf of someone else, you must complete section 2; if not, go to section 3.

 

Complaining on behalf of someone else.

ONLY complete this section if you are making a complaint on behalf of someone else.

I am making this complaint on behalf of:

Name
Address 1
Town
County
Home telephone number
Daytime telephone number
Email address
What is your relationship to the person who has the complaint?
Please explain why the person is not making the complaint?

Which dentist are you complaining about?

Dentist's name
Have you complained to the dentist or their practice?
If yes, please give names and, if possible, job titles of the person(s) you contacted:
Was your complaint made
in writing?
Have you received a reply?
Have you contacted anyone else about your complaint?
If yes, please say who and what the outcome was:

What are you complaining about?

Describe the complaint

What do you want the Dental Complaints Resolution Service to do?

Describe the action to be taken

Have you taken, or are you planning to take legal action?

Are you planning to take
legal action?

(If yes, this may affect our ability to consider your complaint – please call our helpline)

How did you find out about the Dental Complaints Resolution Service?

Describe the action to be taken