eConsult

Fill out a simple online form to get advice and treatment by the end of the next working day.

Register as a Carer Form

If you are an adult who helps to support a relative, partner, friend or neighbour who is ill, frail, has a physical or learning disability or who has mental health or alcohol and/or drug problems, then you are a carer.

Please complete the from below. The surgery will record in your notes that you are a carer. This can help us provide you with help with; arranging repeat prescriptions, flu immunization, annual health checks and arranging appointments which fit in with your caring responsibilities.

Tell us what information and support you want by ticketing the boxes below.

Register as a Carer

Carer Details

Enter Email
Confirm Email
Please use format day/month/year e.g. 12/05/1979
Your Address
Town/City
County
Postcode
Country
Are you an employed carer? *
Are you a paid carer in receipt of carer’s allowance? *

Maximum file size: 10MB

Details of Person You Care For

Please use format day/month/year
Address of person you care for
Town/City
County
Postcode
Country
CARER CONSENT
Tick all that are appropriate
How would you prefer to receive information
*
Please tick the box indicating the information that you would like to be sent to you
From The GP Practice
From Carers Support Service
CARED FOR PERSON – OPTIONAL CONSENT
Is the Cared for Person able to give consent *
Would the cared for person like to give consent?
Please tick all that is appropriate *

Privacy Policy

This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data.