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Sample Consent Form Full name of patient:_______________________________________
Address:_______________________________________ _______________________________________ _______________________________________ Date of birth:_______________________________________ Connection to person making the complaint:_______________________________________ I hereby authorise:
Address of person: (if different from above) _______________________________________ _______________________________________ _______________________________________ 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:_______________________________________
Southern Health and Social Services
Council, Quaker Buildings, High Street, Lurgan, Co. Armagh, BT66
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