Register as a carer

Section

Address including postcode:

Which method of communication would you prefer us to use: *

Mobile Contact Number

Home Contact Number

Email address

Relationship to the person you care for: *

Family

Friend

Neighbour

Relationship:

Eg. Mother, daughter, son

Are you a patient at Larkside? *

Yes

No

Who do you care for?

Please tick all boxes that apply

I am the main Carer: *

Yes

No

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

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

Yes

No

I give permission for my details to be passed to the local Carers support centre for advice and support: *

Yes

No

I consent to being registered as a carer with this practice: *

Yes

No

Is the person you care for registered at Larkside Practice? *

Yes

No

Details of Person Being Cared For

Full Name:

Date of Birth:

Please use this date format: DD/MM/YYYY.

Mobile Contact Number:

Home Contact Number:

Email Address:

Address including postcode:

I give consent for the above information about me to be recorded on the clinical record of the person who cares for me:

Yes

No

I give consent 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

Please note that Registering as a Carer doesn’t automatically entitle you to access the medical records of the person you care for. Please ask the surgery for more information if required.

Declaration

I confirm that: *

The information I have given in this form is correct

I consent to my information being used for the purposes described above and wish to submit this online form to the Larkside Practice

If applicable:

I am the parent or legal guardian of the dependent person and I am making a choice for set out above

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Section

Details of Person Being Cared For

Declaration