Register a Carer

Many people look after family members, friends or neighbours who can’t manage without them (because of a health condition, disability, mental health, illness, frailty, addiction or substance misuse).

Do you look after someone – a relative, friend or neighbour who is ill, frail or disabled and is unable to or has difficulty looking after themselves?  Do you give support to someone who has mental health needs or misuses alcohol or drugs?  If so you are a Carer.  You can be a Carer for someone at any age.

If you are, that means you are an informal carer (ie. not employment by a Carer Service) and by registering that you are a carer with the Practice it could mean that we are able to offer you more support.

It is important that we know if you are a carer so that we can make sure you receive information, services and the help that is available. If you are a carer please complete this form.

Register a Carer

Register a Carer

If you are human, leave this field blank.

Carer Details

Full Name: *

Date of Birth: *

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

Mobile Contact Number:

Home Contact Number:

Email Address: *

Any responses we send will go to this email address.

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?

Carer for a friend

Carer for a Neighbour

Carer for a relative

Carer of a person with a Terminal Illness

Carer of a person with Chronic Disease

Carer of a person with Mental Health problem

Carer of a person with Physical Disability

Carer of a person with Learning Disability

Carer of a person with Sensory Impairment

Carer of a person with Dementia

Carer of a person with Substance Misuse

Carer of a person with Alcohol Misuse

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