Carer Registration and Consent Form

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 you are, that means you are a carer and by registering that you are a carer with the Practice it could mean that we are able to offer you more support.

Carers Details

Surname

Forename

Address

Home No

Mobile No

Date of Birth

Relationship to person cared for

I live with the person I care for

I am their next of kin

I am their emergency contact

I am the main carer

If I have a health problem I may need the practice to see me during limited times or to provide a home visit

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

I give consent to being registered as a carer with this practice

Details Of Person Cared For

Surname

Forename

Address

Home No

Mobile No

Date of Birth

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

I give consent for the details of my carer to be held on my medical records.

I give consent for relevant medical information to be shared with my carer.

Your declaration

I confirm that:

The information I have given in this form is correct

I am the parent or legal guardian of the dependent person I am making a choice for set out above (if applicable)

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to City Way Medical Practice • 65-67 City Way, Rochester, Kent, ME1 2AY.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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