Patient Consent Form | Alliance for Better Care

Patient full name (of person affected) *

Full name of person making the complaint on patient behalf *

I confirm that I support the complaint *

I understand that access to my personal information and/ or my medical records will be required in order to investigate this complaint and may be seen by the people involved in investigating and responding to my complaint. *

I understand that relevant personal information about me may be shared and gathered from Alliance for Better Care to help them investigate and respond to my complaint. *

I understand that Alliance for Better Care may need to share this information with other agencies to help them investigate and respond to my complaint *

I authorise the above name to act on my behalf during the consideration of my complaint and I give permission for my information which the organisation holds as confidential to be shared with them. *

I understand that this authority is for an indefinite period relevant to the case *

My full name *

My home address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

My phone number *

My date of birth (DOB) *

Relationship to the person making the complaint on my behalf *