Register as a carer

I am completing this form to ask that you flag on my GP patient record that I am unpaid carer

A carer is defined as those who are in receipt of a carers allowance, or those who are the main carer of elderly or disabled person who is at increased risk of COVID19 whose welfare may be a risk if the carer falls ill.

Address including postcode:

Details of Person Being Cared For

Full Name:

Date of Birth:

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

Address including postcode:

What relation to you is the person being cared for?

Is the person you care for a patient at this surgery?

Yes

No

I can confirm that I am providing unpaid care for a disabled or elderly person who is at increased risk of COVID19 whose welfare may be at risk if I were unable to provide that care. I would like to request that you add to my patient record that I am an unpaid carer

*

I can confirm that I will notify the surgery immediately should I cease to care for the person named above

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Details of Person Being Cared For