CARERS REGISTRATION FORM

If you care for, or help, someone with an illness, physical disability or mental health difficulty, whether this is a partner, friend, relative or neighbour, then you are a CARER.

Here at the Park surgery, we are compiling a register of all our patients who are caring for others. This register will help us to acknowledge you and your needs as a carer and provide you with further information where appropriate.

In order to help us we would be grateful if you would fill in the information requested below, sign and hand this form in at the reception desk.

Your details

Name ……………………………………………..…………. D.O.B ……………….…….

Address ……………………………………………………………………………………..

………………………………………………………………………………………………..

Mobile number……………………………Home Number……………………………….

Email Address……………………………………………………………………………….

Your ethnicity e.g. White British, Black African …………………………………………

I give consent to be added to the Carers Register at my GP practice.

Signature …………………………………………….…………. Date …………………..

Please Turn over

Carers who provide regular and substantial care are legally entitled to a Carers’ Needs Assessment.

** Please sign and date below if you would like to be referred to Adult Care Services for an assessment of your caring situation (Carers’ Needs Assessment).

Signature …………………………………………….…………. Date …………………..

Details of the person cared for

Name ………………………………………………………………………………………..

Date of birth ………………………………………………………………………………...

Relationship to the carer …………………………………………………….…………….

Type of illness or disability ………………………………………………………………..

………………………………………………………………………………………………..

Optional consent from the person cared for

I consent to information about my health being discussed with the person named on this form as my carer.  I consent to my named carer being recorded on my medical records and that this person may request and/or collect my repeat prescriptions and test results.  I will contact the practice if this information changes.

Signature ……………………………………………………. Date ………………………

For GP staff use only:
Carers Information Pack given to carer                           yes / no
Carer added to Carers Register                                      date …………...  
Carer referred to Carers Support Service                       date …………...    
(optional, consent from Carer required)