Tell us if you’re a carer

GP Carers Identification and Registration Form

Do you look after someone who has a long term health condition or illness, a disability or a mental health issue? You can be offered information, support and access to services through Caring for Carers at Improving Lives Plymouth. This Form will enable you to be registered with Caring for Carers as a carer and gives us permission to keep your information on file and send relevant information to you in regard to services available to you, including a regular newsletter.

If you would prefer to print out a form and handwrite it, please click this link gp-carers-identification-and-registration-form.pdf

Carers Information:

Name of your GP surgery(Required)

Title(Required)

Full Name(Required)
First Last

Date of Birth(Required)
DD slash MM slash YYYY

Full Address(Required)
Street Address City Postcode

Phone Number(Required)

Email Address

Have you served in the armed forces or did you complete national service?(Required)

Who do you care for?(Required)

Relative

Child

Neighbour

Partner

Husband

Wife

Other

Information about the person who is being cared for:

Title(Required)

Full Name(Required)
First Last

Date of Birth(Required)
DD slash MM slash YYYY

Have you served in the armed forces or did you complete national service?(Required)

Carers Signature:(Required)
Click the circular arrows symbol to re-set your signature

Date(Required)
DD slash MM slash YYYY

Cared for signature:(Required)
Click the circular arrows symbol to re-set your signature

Date(Required)
DD slash MM slash YYYY

By signing this form you are giving consent to share your details with Caring for Carers and their partners and Plymouth City Council. Your details will be treated in the strictest confidence and in accordance with General Data Protection Regulation (GDPR)

What happens to my information?

Personal and medical information about patients registered at Peverell Park Surgery is primarily kept electronically, although some is kept in paper form. Some information will be sent to hospital consultants and other health professionals to whom you are referred by your GP in order to provide continued healthcare and obtain treatment for you. We sometimes use accredited suppliers for our communication with you (please refer to our Privacy Policy), for example when we send recall letters for review clinics or medication reviews. All suppliers we use are checked carefully to ensure they comply with strict confidentiality protocols. To ensure the security of all patient information, all staff that has access to your records is covered by confidentiality clauses in their contracts and the Data Protection Act and the Freedom of Information Act. Our guiding principle is that we hold your records in strict confidence.

Consent(Required)
I certify that the information I have provided is correct and consent to my personal and medical information being used as stated above.

Name
This field is for validation purposes and should be left unchanged.

71940

Peverell Park Surgery & University Medical Centre

Tell us if you’re a carer

GP Carers Identification and Registration Form

Carers Information:

Information about the person who is being cared for:

What happens to my information?

Check out our CQC report

Peverell Park Surgery & University Medical Centre

Tell us if you’re a carer

GP Carers Identification and Registration Form

Carers Information:

Information about the person who is being cared for:

What happens to my information?

Check out our CQC report

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