Carers Registration Form

If you are someone that helps to support a relative, partner, friend or neighbour who needs help and support because they are frail, has physical or mental disability or alcohol and drug dependencies YOU ARE A CARER.

Please complete this form. We will record in your notes that you are a carer and if the person you care for is also registered we will add in their notes that they are cared for by you.

The benefits of registering as a carer with us are to help you arrange repeat prescriptions, immunisations, and arranging appointments that will fit in with your caring responsibilities.

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Carer Information
Title: *
Carer Consent

Please tick:

Once you have been referred to Carer’s Support they will contact you and provide personalised information relevant to you and your needs.

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Cared for Person Consent (optional)

I consent for information about my health and wellbeing to be discussed with the person named on this form as my carer. I consent for my named carer being recorded on my medical records and that this person may request and/or collect my repeat prescription, test results and have access to online appointments and prescriptions.

I will contact the surgery if this information changes.

Title:

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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