Consent Form
Patients authorising someone else to complain on their behalf.

Full Name of Patient: ______________________________________________

Address:   ________________________________________________________________
________________________________________________________________
________________________________________________________________

Date of Birth: _____ / _____ / __________  

Name of person making complaint: __________________________________

Relationship to patient: ___________________________________________

Address: ________________________________________________________________
________________________________________________________________
________________________________________________________________

I_______________________ give my permission for_____________________ to investigate this complaint and, where necessary obtain disclosure of relevant personal and confidential information.

I understand that __________________________ will use any information gathered to assist in the investigation of this complaint.

Signature of patient: __________________________________________

Date: _____ / _____ / __________