Register as a Carer Form

Carer Details

Your First Name *

Your Last Name *

Your Email *

Your Date of birth *

Please use format day/month/year e.g. 12/05/1979

Your Phone Number *

Your Address, including postcode *

Do we have permission to record your contact details in the notes of the person being cared for in case of emergency? *

Yes

Are you, as the carer, registered as a patient at The Chaucer Surgery? *

Yes

As a carer, you are entitled to an NHS seasonal 'flu vaccination. Is this something you would be interested in having? *

Yes - I am a Chaucer registered patient and would like to be invited for the 'flu jab

Yes - I am registered elsewhere and will contact my own GP surgery for the 'flu jab

No thanks - I do not want a 'flu jab this year.

Flu vaccinations are offered at GP practices each Autumn. For further information about the vaccinations, see the NHS website: https://www.nhs.uk/conditions/vaccinations/flu-influenza-vaccine/

Details of Person You Care For

First Name *

Last Name *

Date of birth *

Please use format day/month/year

Address, including postcode *

Is the person you care for registered as a patient of Chaucer Surgery? *

Yes

If you are both patients at our surgery, your records will be cross-referenced to ensure our information is correct and up to date.

Has the person you care for been diagnosed with dementia? *

Yes

Do you, or the person you care for, have any concerns regarding their memory? *

Yes

All carers are entitled to an assessment of their needs through 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. *

Yes - please refer me to Adult Care Services for a Carer's assessment

Yes - please refer me for a Young Carer's Assessment (under 16's only)

No thank you, we already have support or this is something we don't need right now.