Are You a Carer? Are you a Carer? Please let us know Carer Form If you are a patient of Elsenham Surgery and look after somebody who is ill, frail, disabled or mentally ill please complete the form below. It is important for your own health and welling that we are aware that you are a carer so that we may support you in your role. Who Can Have “carer status” Who is a carer?: If care for somebody full – or part-time. The person you care for can be a relative, spouse, friend or neighbour. The person you care for does not need to be registered as a patient at Elsenham Surgery. If you are in any doubt with regard to you carers status please call 01279 814730 and ask for Sue Richardson the Carers Champion. Please DO NOT share any personal or private information regarding anybody that is not registered at this surgery. Please note this information is for surgery use only. Please notify us should you stop being a carer. Patient Name (Name of Carer) * Carers Telephone Number * Carers Address * Carers Address Carers Address Carers Address Postcode Postcode City City Country Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Country Age Range of The Person being cared for e’g Child 20’S 30’S 80’S etc * Your relationship to the person being cared for e.g spouse, neighbour etc. * Is the person you care for also a patient at Elsenham Surgery? * Yes No What is their name? * Any Relevant Information For Example – I care for somebody who has dementia, had stroke, has Cancer etc. To help us help you in your role as a carer please confirm your consent to one or more of the following; Yes please, I would like to receive communications by email Yes please, I would like to receive communications by mobile phone including text message Yes please, I would like to receive communications by post Please add Carer Status to my medical record Please enter your full name to sign: * Today’s Date * If you are human, leave this field blank. Submit Start Over