Carer Registration

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Carers Identification and Consent Form

Do you look after someone - a relative, friend or neighbour who is ill, frail or disabled and is unable to or has difficulty looking after themselves? Do you give support to someone who has mental health needs or misuses alcohol or drugs?

If you are, that means you are 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.

Please complete the following form.

Carer Details

Please double check you've entered the correct email address

I live with the person I care for: *

I am their next of kin: *

I am their emergency contact: *

I am the main carer: *

If I have a health problem I may need the practice to see me during limited times or to provide a home visit: *

I give permission for my details to be passed to the Carers support centre for advice and support: *

Details Of Person Being Cared For

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

If the person who is cared for is not registered at Gloucester Road Medical Centre, please ensure that their own GP is aware they have a carer.

Access Records

In some circumstances, it can be useful for your carer to be able to access your medical information. If you consent to this happening, please read below and sign if you are happy with this statement.

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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Carers Identification and Consent Form

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