Carers Identification and Consent Form

A carer is someone who provides support to someone who could not manage without this help. This could be caring for a relative, partner, friend or neighbour who is frail, disabled, has learning difficulties or has a mental health or substance misuse problem. All the care they give is unpaid.

If this sounds like you, 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 this form.

Carers Identification and Consent Form

Your Details as Carer

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
*

Details of Person Cared For

This section is about the person cared for and requires completion and signature by them.
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.
I give consent for relevant medical information to be shared with my Carer: