Register a Carer

If you are an unpaid carer for a relative, friend, partner or child who is frail, disabled or chronically ill, please register as a carer using the form below.

Carer Details

Full Name: *

Date of Birth: *

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

Email Address: *

By giving us your email address on this online form, we assume consent to reply to this form via email when necessary. If you prefer not to receive email, please contact the surgery by telephone.

Phone Number:

Address including postcode:

GP Surgery:

Do you have any communication/information needs relating to disability, impairment or sensory loss?

Yes

Please be specific:

Signature:

Implies consent to record your details on the notes of the person you care for.

Date:

Details of Person Being Cared For

Full Name: *

Date of Birth: *

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

Address including postcode:

GP Surgery:

Signature:

Implies consent to record your details on the notes of your carer.

Date:

If you are both registered at QJS your records will be cross-referenced.

Has the person you care for been diagnosed with dementia?

Yes

Do you or the person you care for have concerns about their memory?

Yes

All carers are entitled to an assessment of their needs, by Social Services. An assessment is intended to provide additional help and support if needed. The needs of the person you care for can also be assessed and this could be done separately or together, depending on the situation. We can refer you for an assessment if you wish.

Carers Assessment

Please refer me to Adult Care Services for a Carers Assessment.

Please refer me for a Young Carers Assessment (under 16’s only).

Carer Details

Details of Person Being Cared For

Online Forms

Online Services

General Services

Practice Policies