Are You a Carer?

Do you look after a family member or friend who is unwell, disabled or frail? If so please complete this form. Once you are added to our list of carers we will know about your busy life as a carer which can affect your health. We can also try and be flexible with appointments etc as we will know about your commitments. We can also make sure you receive information, services and the help that is available.

Last Updated: 23/02/2021

Carer Details

Your Name *

Date of Birth *

Phone Number

Email Address *

Address *

Postcode *

Details of Person Being Cared For

Their Name *

Date of Birth *

Address *

Postcode *

What is your relationship to the person being cared for? *

Is the person you care for a patient at Lodge Surgery? *

Yes No

Alternative Contact Person

Full Name

Relationship

Telephone No

Would you like to receive twice yearly newsletters from Carer Support Wiltshire? *

Yes No

Please confirm you are happy for us to pass on your contact details to them? *

Yes No

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. *

I consent to the practice collecting and storing my data from this form.

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