Carer Form

Being a Carer can often affect your own health. By letting your GP surgery know that you are caring for someone could help your GP offer you better support. A carer is someone who, without payment, provides care and support to a relative, partner, friend or disabled child who cannot manage without your help. As a carer your health is as important as that of the person that you care for, as it ensures that you can continue to carry out your caring role. By completing this form we will refer you to the external carer support service Carers First who can help with specialist advice & information, practical help with completing forms, gaining benefits, grants & other funding and much more.

Last Updated: 22/09/2020

About Me - The Carer

Full Name *

Date of Birth *

Address *

Postcode *

Home Phone Number

Mobile Phone Number

Email Address

I give consent to share my contact details with the external carer support service - Carers First *

Yes No

Date

Signature

About the person I care for

Please only complete this part of the form if you have consent from the person you care for

Full Name *

Date of Birth *

Address *

Postcode *

Home Phone Number

Mobile Phone Number

Email Address

Relationship to me *

Signature *

Date

I have a carer who supports me and I would like this recorded on my patient record and I understand that my records may be linked to my carer’s patient records *

Yes No

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Carer Form

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