Community Surgery

Consent & Authority Form

This form allows me to understand your enquiry and, where appropriate, make enquiries or communicate with relevant organisations on your behalf. I will only ask for personal information that is reasonably necessary to understand and assist with your particular issue.

1. Your Details

Full Name *

Address *

Postcode *

Phone

Email *

Preferred method of contact:

Telephone
Email
Text/Whatsapp
Other

2. Your Issue

Brief description of the matter

Relevant organisation, council department, landlord, housing provider or other body, if known

Reference / case number, if applicable

3. Identification

Depending on the nature of your enquiry, I may need to see identification or proof of address, particularly where another organisation requires confirmation of your identity before it will discuss your case. Please provide identification only where necessary.

Please provide identification only where it is necessary for your case.

Identification seen or provided

Where possible, identification will be used for verification rather than retained unnecessarily.

4. Permission to Act on Your Behalf

Consent1 *

Yes, I give my authority *

To assist with your enquiry, I may need to contact organisations such as the local council, housing providers, government departments, public authorities, service providers or other organisations relevant to your case.

I authorise Ghaalib Shahidullah to make enquiries and communicate with relevant organisations on my behalf in relation to the issue described above.

Consent2 *

Yes, I give my authority *

I understand that this may require relevant personal information to be shared with those organisations, but only where reasonably necessary for dealing with my enquiry.

I also authorise relevant organisations, where permitted, to discuss my case and provide information relevant to this enquiry to Ghaalib Shahidullah.

5. Sensitive Personal Information

Consent3 *

I explicitly consent to the relevant sensitive information being used for the purpose of understanding and assisting with my enquiry and, where necessary, being shared with the organisation dealing with my case. *

Some enquiries may involve particularly sensitive information, for example information concerning health, disability, ethnicity, religion, political opinions, trade union membership, sexual orientation or other personal circumstances.

You do not need to provide this information unless it is relevant to your enquiry.

Where you voluntarily provide sensitive personal information that is necessary for dealing with your case

6. How Your Information Will Be Used

Information provided through the Community Surgery will be used for purposes such as:

understanding your enquiry; communicating with you; maintaining an appropriate record of the matter; identifying the organisation or authority responsible; contacting relevant organisations where you have authorised me to do so; following up your case; and informing you of progress or responses relating to your enquiry. Only information reasonably necessary for these purposes will be collected and used.

7. Keeping Your Information

Information relating to your enquiry will be kept securely and only for as long as reasonably necessary for dealing with the case and meeting any applicable legal or record-keeping requirements. Information that is no longer required will be securely deleted or destroyed.

Further details about how personal information is handled, retained and protected are available in the Community Surgery Privacy Notice at:

[WEBSITE / PRIVACY NOTICE LINK] You may also request a copy.

8. Your Choices and Rights

You may contact me if you wish to:

correct inaccurate information; ask what personal information is held about you; raise a concern about how your information is being used; withdraw an authority or consent where the processing relies upon it; or ask for information to be deleted where applicable.

Withdrawal of permission will not affect anything lawfully done before it was withdrawn, but it may mean that I am unable to continue making enquiries on your behalf.

Contact: Ghaalib Shahidullah
Email: ghaalib@shahidullah
Telephone / WhatsApp: 07763612660

You may also have the right to raise a concern with the Information Commissioner’s Office (ICO).

Phone is Name

Your Authority

I confirm that:

The information I have provided is accurate to the best of my knowledge.
I have read and understood how my information may be used for the purposes of this Community Surgery enquiry.
I authorise Ghaalib Shahidullah to act and make enquiries on my behalf as described above.

Name *

Signature *

Clear Signature

Date *

For remote enquiries

Where this form is completed electronically:

By ticking this box and submitting the form, I confirm that I give the authority described above.

Optional – Staying in Contact

This is entirely separate from your Community Surgery enquiry.

Checkboxes

Yes, I would like to receive occasional updates from Ghaalib Shahidullah about local community matters, activities and public meetings.

Email / Mobile for updates:

You can unsubscribe or withdraw this permission at any time. Choosing not to receive updates will have no effect whatsoever on your Community Surgery enquiry or any assistance provided.