Third Party Patient Complaints Form Patient DetailsTitleMissMsMrsMrDoctorOtherName First Last Date of Birth DD slash MM slash YYYY Telephone NumberAddressPostcodeThird Party DetailsTitleMissMsMrsMrDoctorOtherName First Last Date of Birth DD slash MM slash YYYY Telephone NumberAddressPostcodeDeclarationConsent 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/for a limited period only*.Where a limited period applies, this authority is valid unti DD slash MM slash YYYY SignatureSurname & InitialsTitleMissMsMrsMrDoctorOther