ARE YOU A CARER?

 

 

 

Does someone at home or in the neighbourhood depend on you to help

 

with the tasks and/or responsibilities of everyday living?

 

Perhaps you care for someone in the family or for a friend?

 

Is so, you are a carer and might like some support yourself.

 

Or you might need to discuss the care required for the person you are caring for.

 

If so ask one of the receptionists for a carers consent form and a resource pack or 

 

copy and paste the form below into a word document, complete it and send or

 

give it to the practice.

 

The form cannot be submitted online as it requires a written signature.

 

DURNFORD MEDICAL CENTRE

 

CARERS DETAILS AND CONSENT FORM

 

 

I consent to the following information being held on the practice’s database:-

 

MY DETAILS:

 

NAME………………………………………………………….

DATE OF BIRTH:…………………………………..............

 

ADDRESS:…………………………………….....…………..

...................................................………………....

 

POST CODE:……………………………………………..….

 

HOME TEL:……………………………………………….....

MOBILE :…………………………………………………....

 

WORK TEL:……………………………………………….....

 

MY RELATIONSHIP OF PERSON I CARE FOR:………………………………………………………………

(FOR EXAMPLE – PARENT,CHILD,FRIEND,NEIGHBOUR)

 

 

CARER SIGNATURE……………………………………………………

DATE:…………………………………….....................................

 

 

Please complete below if the person you are caring for is also a patient here and they are happy for you to discuss their care with the medical and admin staff.

 

I AM THE CARER FOR:

 

 

NAME:…………………………………………………………

DATE OF BIRTH:…………………………………..............

 

ADDRESS:………………………………………..………….

.................................................................................

 

POST CODE:……………………………………………..…

TEL NO:……………………………………………….........

 

 

I consent to my carer being able to discuss details from my medical records.

 

 

SIGNED:………………………………………………………………..…

DATE:………………………………….........................................…