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.

Your title

Please select your title from the options below

Mrs

Miss

Other

First name

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Surname

Please enter your surname in the field below

Your home address

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Postcode

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Your date of birth

Please enter your full date of birth in the field below

Your telephone number

Please enter your telephone number in the field below

Your email address

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Confirm your email address

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

If I have a health problem, I find it difficult to come to the surgery because I cannot leave the person I look after; this means that there are only very limited times when I can come to the surgery to attend to my own health needs

Could the Practice offer me an annual appointment to check my health to help me stay as fit and healthy as possible to enable me to continue caring for as long as possible

As a carer you have the right to a Carer's Assessment. This is an opportunity to say what help you need to look after the person you care for. To be referred for a Carer's Assessment please tick the box

Carers Support Centre provides a range of services, support and information for carers. To be referred to the Carers Centre please tick the box

Important:

Combined carers identification and consent form