Consent Form

Instructions (Please read before completing)

Section 1 – This should be completed by everyone

Section 2 – This should ONLY be completed if you are not the patient AND the patient is not deceased.

Section 3 – This should ONLY be completed if you are not the patient AND the patient is deceased

Section 4 – This should ONLY be completed if the consent of a Next of Kin/Power of Attorney for Welfare/Legal Guardian is required and this is NOT the person making the complaint.

If you require any help in completing this form, please contact us on 0131 314 0000

Section 1: Patient Details
Please enter the full name of the patient
Please enter address of the patient
Please enter a contact telephone number for the patient
Please enter a contact email address for the patient

If you answered no to the question above, please complete the following two questions

Please let us know your relationship to the patient

If you answered yes to the question above, go to section 3, if no go to section 2

Section 2: Complainant Details - if different to the patient (only complete this section if the patient is not deceased)
Please enter the name of the person making the complaint
Please enter name of person making complaint
Please enter a contact telephone number for the Legal Guardian

If you selected no to the question above, the Service is bound by the Data Protection Act (Scotland) 2018 and GDPR UK so there for will be unable to provide any personal information, without the express permission of the data owner (the patient). This includes details of calls in relation to the patient(s) or any care that the Service provided to the patient(s).

Section 3: Complainant Details - if different to the patient (only complete this section if the patient is deceased)

If you selected no to the Service contacting the next of kin, the Service is bound by the Data Protection Act (Scotland) 2018, GDPR UK and the Access to Medical Health Records Act 1990 so there for will be unable to provide any personal information, without the express permission of the data owner (the patient’s Next of Kin). This includes details of calls in relation to the patient(s) or any care that the Service provided to the patient(s).

Section 4: Next of Kin/Legal Guardian Details/Power of Attorney for Welfare
Authorisation
In This Section