Full name of patient

_______________________________________

 

Address:	_______________________________________
	_______________________________________
	_______________________________________

 

Date of birth:

_______________________________________

 

Connection to person making the complaint:

_______________________________________

 

I hereby authorise:

_______________________________________

 

Address of person:	_______________________________________
	_______________________________________
	_______________________________________

 

to act on my behalf and to receive any and all such information as may be relevant to my complaint.

I understand that any information given about myself is limited to that which is relevant to the investigation of the complaint, and only disclosed to those people who have a need to know it in order to investigate the complaint.

 

Signature of patient:

_______________________________________

 

Date:

_______________________________________