Patient Full Name:
Date of Birth:
Address:
Complaint details: (Include dates, times, and names of practice personnel, if known)
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SIGNED…………………………………. Print Name………………………………….. Date………………………. (Continue overleaf if necessary)
Office Use Only
Date Complaint In ……………………………… Clinician Involved…………………………………….
PATIENT THIRD-PARTY CONSENT
PATIENT’S NAME: ______________________________________________
TELEPHONE NUMBER: ______________________________________________
ADDRESS: ______________________________________________ ______________________________________________
ENQUIRER / COMPLAINANT NAME: _______________________________________ TELEPHONE NUMBER: ______________________________________________
ADDRESS: ______________________________________________ ______________________________________________
IF YOU ARE COMPLAINING ON BEHALF OF A PATIENT OR YOUR COMPLAINT OR ENQUIRY INVOLVES THE MEDICAL CARE OF A PATIENT THEN THE CONSENT OF THE PATIENT WILL BE REQUIRED. PLEASE OBTAIN THE PATIENT’S SIGNED CONSENT BELOW.
I fully consent to my Doctor releasing information to, and discussing my care and medical records with the person named above in relation to this complaint only, and I wish this person to complain on my behalf.
This authority is for an indefinite period / for a limited period only (delete as appropriate) Where a limited period applies, this authority is valid until…………………….. (Insert date)
Signed: ………………………………………. (Patient only)
Date: …………………………………………..