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Carer Identification and Referral

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Here at the surgery we keep a register of all our patients who are caring for others. The register helps us to recognise your needs as a carer and provide you with further information and support.

Please complete the following form to register as a carer:

Carer Details

Please note all fields marked with a * are mandatory for your registration

Title: *

Details of Person Being Cared For

Title: *

Further Details

Additional Consent

I wish to be added to Worthing Medical Groups Carers register: *

I wish to be referred to Carers Support West Sussex and am happy for Carers Support West Sussex to contact me: *

I would like to be invited to all Carers events in the surgery: *

Person Being Cared For Consent

I consent to information about my health being discussed with the person named on this form as my carer: *

I consent to my named carer being recorded on my medical records and that this person may request and/or collect my repeat prescriptions and test results: *

Declaration

Privacy Consent

This form collects personal and medical information about you and we use this information to allow the practice team to contact you.
Please read our Privacy Policy to discover how we protect and manage your submitted data.

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Carer Identification and Referral

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