Care Registration and Consent

Section

Title: *

Mr

Ms

Miss

Other

Address: *

Relationship to person cared for: *

Please give a brief summary of health problems of the person you care for: *

I live with the person I care for: *

Yes

No

I am their next of kin: *

Yes

No

I am their emergency contact: *

Yes

No

I am the main carer: *

Yes

No

Is the person you care for over or under 18? *

Over 18

Under 18

I give consent to being registered as a carer with this practice:

Signature: *

Date:

I give permission for my details to be passed to the local carers support centre for advice and support: *

Yes

No

Protected Characteristics: these are not mandatory to answer, however they will help us to improve our service.

Ethnic origin:

Religion:

Sexual Orientation:

Do you have a disability?

Yes

No

Do you identify as transgender?

Yes

No

Details of person being cared for

This section should be completed by the person you care for. This is to make sure that they give their consent to register you as their carer.

First Name: *

Surname: *

Address: *

Home Number: *

Mobile Number: *

Email Address: *

Date of Birth: *

Please use this date format: DD/MM/YYYY.

I give consent for the above information about me to be recorded on the clinical record of the person who cares for me: *

Yes

No

I give consent for the details of my carer to be held on my medical records: *

Yes

No

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

Yes

No

Signature: *

Date:

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Section

Details of person being cared for