Register as a Carer

By identifying yourself as a carer, we will be able to

support you and signpost you to the support services

available to you as a carer.

Carer Details

Name *

Date of Birth *

NHS Number

Address *

Postcode *

Phone Number *

Email Address

Details of Person Being Cared For

Name *

Date of Birth *

NHS Number

Address *

Postcode *

What is your relationship to the person being cared for? *

Is the person you care for registered at this surgery *

Yes No

Details about the care you provide:

Would you like us to pass your details to the local carer support services? *

Yes No

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

The information you provide on this form will be sent to our practice and used only to deal with your request. Depending on the form, this may include your contact details, personal information and health information. The practice may add it to your medical record and, where needed for your care, share it with other NHS and care services. To find out how we protect and use your information, please read our privacy policy on our website.

I confirm the information I’ve given is correct and I understand how it will be used

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Page last reviewed: 03 June 2024
Page created: 27 October 2026

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Register as a Carer

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