Your Name (required)
Your Address
Town
County
Your telephone number
Your Email (required)
Your date of birth
Which dentist are you complaining about?
Have you complained to the dentist? YesNo
If yes, please give names and, if possible, job titles of the person(s) you contacted:
Was your complaint made in writing? YesNo
Have you received a reply? YesNo
Have you contacted anyone else about your complaint? YesNo
If yes, please say who and what the outcome was
What is your complaint?
What would you like the Dental Complaints Resolution Service to do?
Please tick this box to allow us to share information with the dentist and for the dentist to share with us.
