Complaint Authorisation Form – Third Party Consent

If you are complaining on behalf of someone else we need to ensure that they consent to this due to the confidential nature of the information which may be shared. Please complete the form below and you will need to provide the surgery with the appropriate identification.

Patients Name:

Patients Address:

Patients Date of Birth:

Do you (the patient) authorise this complaint to be made on your behalf by the nominate person named below?

Do you agree that the Practice may disclose the necessary confidential information to answer the complaint?

Name of Nominated Person:

Contact Telephone Number for Nominated Person:

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Cowdenbeath Medical Practice • 173 Stenhouse Street, Cowdenbeath, Fife, KY4 9DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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