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

    Date of Birth
    For example, 15 3 1984

  • Details of Person Being Cared For

    Date of Birth
    For example, 15 3 1984
    Is the person you care for a patient at Lodge Surgery?

  • Alternative Contact Person

    Would you like to receive twice yearly newsletters from Carer Support Wiltshire?
    Please confirm you are happy for us to pass on your contact details to them?
    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.
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