ARE YOU A CARER?

Are you looking after or providing support for a relative friend or neighbour? Are you being helped or supported by a relative friend or neighbour?

Your GP needs to know so you can be offered the right information, support and access to services. GP surgeries have to compile information for the government about the numbers of carers attached to the surgery so your information will help them to do this.

Please complete the form below.

About You - The Carer

Your Name: Address: Date of Birth: Contact Details:

About Your Cared For

Their Name: Date of Birth: Contact Details: Relationship - Spouse, Parent, Child, Friend, Neighbour, Other:

Are you their Next of Kin?

Yes

Are you their main carer?

Yes

Primary reason for care - Frail, Elderly, Dementia, Parkinsons, etc:

Confirm your Location

I confirm that I am a patient at Grove House Surgery, Shepton Mallet, Somerset.

Information provided by you through this form will allow us to improve our services. The form data undergoes encryption during transmission and while at rest, and will only be retained for a duration sufficient to process your request. You have the option to withdraw your request at any time by notifying the practice. By using this form you are agreeing to our privacy guidelines.

Submit your Request

Thank you! Your submission has been received!

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ARE YOU A CARER?

About You - The Carer

About Your Cared For

Confirm your Location

Submit your Request

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