Third Party Complaint Declaration

Pathfields Medical Group allows a third party to make a complaint on behalf of a patient. The patient must provide consent for them to do so. This can be done via this form or alternatively collect a paper version via one of our surgeries.

Patient Forename

Patient Surname

Date of birth

Contact number

Home address

Postcode

Email address

Forename

Surname

Date of birth

Contact number

Home address

Postcode

Email address

I hereby authorise the individual detailed in third party section 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.

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.

The day of submitting the application