Carers identification and consent

Your Details as Carer

Address:

Home number:

Relationship to person being cared for:

I live with the person I care for:

Yes

No

I am their Next of Kin:

Yes

No

I am their Emergency contact:

Yes

No

I am the Main Carer:

Yes

No

If I have a health problem I may need the practice to see me during limited times

Yes

No

*

I give consent to being registered as a Carer with this practice.

Signature: *

Date:

Details of Person Cared For

This section is about the person cared for and requires completion and signature by them.

First name: *

Surname: *

Address:

Home number:

Phone number:

Email:

I give consent for my personal details above to be recorded on the clinical record of the person who cares for me and for the details of my Carer to be held on my medical records.

Yes

No

I give consent for relevant medical information to be shared with my Carer:

Yes

No

Signature: *

Date:

Tell us whether you accept cookies

Your Details as Carer

Details of Person Cared For