Selecting the correct consent form for your complaint

To decide which consent form you need to complete, please read the statements below and download the relevant form:

Complaints on behalf of yourself

If you are raising a complaint on behalf of yourself, please use this form:
Consent form IR 075 - for complaints on behalf of yourself (pdf 18kb) (opens new window)
Easy read consent form IR 075 - for complaints on behalf of yourself (pdf 97kb) (opens new window)

Complaints on behalf of someone else

If you have been given authorisation to raise a complaint on behalf of someone else, please use this form:
Consent form IR 090 - for complaints on behalf of someone else (pdf 18kb) (opens new window)
Easy read consent form IR 090 - for complaints on behalf of someone else (pdf 119kb) (opens new window)

If you are raising a complaint on the behalf of someone who is unable to do so by themselves, please use this form:
Consent form IR 095 - for complaints on behalf of someone who cannot do so themselves (pdf 20kb) (opens new window)
Easy read consent form IR 095 - for complaints on behalf of someone who cannot so so themselves (pdf 142kb) (opens new window)

Complaints about care given to a child

If you are raising the complaint regarding the care given to a child, please use this form:
Consent form IR 065 - for complaints about care of a child (pdf 22kb) (opens new window)
Easy read consent form IR 065 - for complaints about care of a child (pdf 206kb) (opens new window)

Complaints regarding a patient who has died

If you are raising the complaint regarding a patient who has died, please use this form:
Consent form IR 070 - for complaints about a patient who has died (pdf 25kb) (opens new window)
Easy read consent form IR 070 - for complaints about a paitent who has died (pdf 165kb) (opens new window)

Ombudsman referral complaint

If your complaint is an Ombudsman’s referral, please use this form:
Consent form IR 085 - for an Ombudsman's referral complaint (pdf 18kb) (opens new window)
Easy read consent form IR 085 - for an Ombudsman's referral complaint (pdf 73kb) (opens new window)

Complaints by those detained in prisons

If you are currently detained in HM prisons and wish to raise a complaint about the NHS service you have received, please use this form:
Consent form IR 100 - for complaints by prisoners (pdf 17kb) (opens new window)
Easy read consent form IR 100 - for complaints by prisoners (pdf 121kb) (opens new window)

Complaints not related to patient treatment

If your complaint does not relate to treatment of an individual patient, please use this form:
Consent form IR 080 - for complaints not related to patient treatment (pdf 19kb) (opens new window)
Easy read consent form IR 080 - for complaints not related to patient treatment (pdf 93kb) (opens new window)

Consent, confidentiality and data protection

Consent, confidentiality and data protection - consent information leaflet (pdf 37kb) (opens new window)

Easy read consent, confidentiality and data protection - consent_information_leaflet (pdf 206kb) (opens new window)

If you are unsure about the correct consent form to use, please contact our helpline:
Helpline and feedback

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