Tell Us You Are a Carer form

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.

Carer Details

Name of Carer *

Carer's Date of Birth (DD/MM/YYYY) *

Carer's Main Contact Phone Number *

Carer's Email Address *

Carer's Address *

Postcode *

Details of Person Being Cared For

Name *

Date of Birth (DD/MM/YYYY) *

Address *

Postcode *

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

Is the person you care for registered at this surgery *

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: 04 September 2022
Page created: 14 October 2026

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Tell Us You Are a Carer form

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