Text Only Version of WHSSC Website - Sample Consent Form

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Sample Consent Form

Full name of patient

Address:

Date of birth:

Connection to person making the complaint:

I hereby authorise:

Name and 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:

Western Health and Social Services Council
‘Hilltop’
Tyrone and Fermanagh Hospital
Omagh
Co Tyrone
BT79 0NS
Freephone: 0800 917 0222
Tel: 028 8225 2555
Fax: 028 8225 2544
Minicom: 028 8224 8389
Email: info@whssc.n-i.nhs.uk
Website: www.whssc.org

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