Register as a carer

Section

Address including postcode:

Details of Person Being Cared For

Full Name:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Address including postcode:

What relation to you is the person being cared for?

Is the person you care for a patient at this surgery?

Yes

No

Declaration

I understand that by ticking this box I am stating that I am a carer. I would like my name to go onto my GP’s carers register and I give permission for this to be recorded on my medical record.

It is important we keep our carers register up to date.

I agree that I will inform the Health Centre should I no longer be a carer.

I am happy for the Health Centre to contact me should they wish to check my carer status.

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Section

Details of Person Being Cared For