Carer Information Form
In line with practice policy we request that you complete the below form to advise us of details of the person you care for and your own details.
This will be recorded on your record if you are a patient of the practice and the person’s record that you care for. We need to have consent from the patient to add details onto their record and therefore request that the patient sign and date this form to show that they are happy for you to be added as a carer on their medical record. Please also let us know if you are a registered carer or whether you are a relative who is caring for the patient.
Fields marked with * must be completed
About This Form
Thank you for agreeing to help us keep our records current and accurate. Please fill in all of the appropriate fields and click ‘Submit’. The symbol * indicates a compulsory field.
Note: By using this form you will be sending information about yourself across the Internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. If this matter concerns you then you should use another method to notify us of your information.
Personal information retained on this system is stored in a secure data centre located in the UK and is treated as confidential.