Carer Registration

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It is important that we know if you are a carer so that we can make sure you receive information, services and the help that is available

If you are a carer please complete this form

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All questions marked with a * are mandatory

Your Details

Please double check you've entered the correct email address

May be used to identify you

I live with the person i care for: *

I am their next of kin: *

I am their emergency contact: *

I am their main carer: *

Is the person you care for under 18?: *

Please sign above t ogive consent to be registered as a carer with Downend Health Group

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Protected Characteristics

Do you have a disability:

Do you identify as transgender?:

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Details Of Person Being Care For

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 record: *

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

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

Please sign above to consent

Date of signature

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This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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If the error persists please contact us.