Register as a Carer

It is important that we know if you are a carer so that we can make sure you receive information, services and the help that is available. If you are a carer please complete this form.

Last Updated: 26/10/2023

Carer Details

Name *

Date of Birth *

Phone Number

Email Address *

Address *

Postcode *

Details of Person Being Cared For

Name *

Date of Birth *

Address - if different to above

Postcode - If different to above

What is your relationship to the person being cared for? *

Is the person you care for registered at this surgery *

Yes No

Do you have a contingency plan in place in the event you are unable to continue to provide care? *

DNACPR / ReSPECT

Please contact the surgery to make an appointment with Chrissi our Paramedic Practitioner if this is something your interested in setting up.

Do you / they have a DNACPR or ReSPECT form in place

Yes No

Resources

We hold a Carers meeting every 1st Wednesday of the month at the Surgery between 12.30 - 2.00 with refreshments available.

We often have representatives from Carers Support, Sage House & our Social Prescriber.

Are you registered with Carers Support

Yes No

Consent

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

I do not consent to the practice collecting and storing my data from this form.

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Register as a Carer

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