Are You a Carer? - Elsenham Surgery

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

Postcode

City

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

Are you a Carer? Please let us know