Third party patient complaint form

Section 1: PATIENT DETAILS

Surname *

Forename *

Date of birth *

Telephone *

Address *

SECTION 2: THIRD PARTY DETAILS

Surname *

Forename *

Date of Birth *

Telephone *

Address *

Section 3: Declaration

I hereby authorise the individual detailed in Section 2 to act on my behalf in making this complaint and to receive such information as may be considered relevant to the complaint. I understand that any information given about me is limited to that which is relevant to the subsequent investigation of the complaint and may only be disclosed to those people who have consented to act on my behalf. *

This authority is for an indefinite period

This authority is for a limited period only (please enter details below)

Where a limited period applies, this authority is valid until:

Consent

This form collects your name, date of birth, email, other personal information and medical details. this is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the nhs. please read our privacy policy to discover how we protect and manage your submitted data. * *

I consent to the practice collecting and storing my data from this form.

If this form is not related to feedback or complaints I consent to this form being discarded, * *

Yes I understand.

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Page last reviewed: 14 May 2026
Page created: 14 May 2026

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Third party patient complaint form

Third party patient complaint form

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