Carer Identification Form

Why this form?

If you look after someone who couldn’t manage without your help due to illness, disability, mental health needs, or addiction, you are a carer. Letting us know helps us support you better.

(To be completed by or on behalf of the carer)

Your Details (The person providing care)

Full Name *

Date of Birth *

Address *

Post Code *

Patient Details (The person being cared for)

Full Name

Date of Birth

Relationship to the carer

Is the patient registered at UHS?

Yes No

Nature of Care Provided

What care do you provide to the patient?

Carer Support Needs

Do you feel you need support in your caring role?

Yes

Not Sure

Would you like someone from the surgery to contact you to discuss support?

Yes No

Consent

Confirmation and Consent *

I confirm that I am the carer of the patient named above

I consent to my details being added to the patient's records, if they are also registered at the University Health Service

I give permission for the GP surgery to contact me regarding carer support

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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Carer Identification Form

Further Information