Carer Information

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.


Patient Details

Patient Name *

Date of Birth [dd/mm/yyyy] *

Address *

KEY Safe Number *

Contact Number

Do you consent to the following person being registered on your record as a carer?

Do you consent to your medical information and treatment being discussed with the below nominated person?

 


Carer Details

Carer Name *

Address *

Contact Number

Are you a relative who cares for a patient?

Please state your relationship to patient *

Are you a registered carer?

If you are employed by an agency to care for patients please give their contact details. *

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