Combined carers identification and consent form

Are you looking after someone, a relative, a friend or neighbour who is ill, frail or disabled and is unable or has difficulties looking after him or herself? Do you give support to someone who has mental health needs or misuses alcohol or drugs?

If you are, that means you're a carer and by registering that you are a carer with the Practice it could mean that we are able to offer you more support or link you up with organisations that could be helpful to you. 

Please complete this form to register as a carer.

About You

Please complete the form with your details as a carer

Your title
Please select your title from the options below
Please enter your first name in the field below
Please enter your surname in the field below
Please enter your home address in the field below
Please enter your postcode in the field below
Please enter your full date of birth in the field below
Please enter your telephone number in the field below
Please enter your email address in the field below
Please re-enter your email address in the field below
Please help us to offer you support that might be useful to you by ticking the relevant box or boxes below

Details of the person being cared for

Please provide the details of the person you are caring for

Title
Please select the title of person being cared for from the options below
Please enter the first name of person you are caring for in the field below
Please enter the surname of person you are caring for in the field below
Please enter the home address of person you are caring for in the field below
Please enter the postcode of person you are caring for in the field below
Please enter the full date of birth of person you are caring for in the field below
Please tell us if you are related, a friend or other connection.
Is the person you care for a patient at this surgery?
Please tick the box to confirm that you understand this form is NOT for urgent medical help
By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. Your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.