Carer Registration Form

If you prefer, you can print a PDF version of this form, fill it in by hand and then send it to the practice.

The Patient

First Name:	*
Last Name:	*
Address:	*
Date of Birth:	*
I give consent for my health needs, medication and treatment to be disclosed by my GP to my carer if they believe that this would be of benefit in providing my care.
I give consent for my details to be provided to Social Services in order that they can arrange an assessment of my needs.
I wish to discuss my care needs with my GP.

First Name:	*
Last Name:	*
Address:	*
Date of Birth:	*
GP Practice:	*
Relationship to Patient:	*
I wish to discuss my needs as a carer with my GP.
I give consent for my details to be provided to Social Services in order to have an assessment of my needs as a carer.
Swindon Carers Centre is a local Princess Royal Trust organisation based in Wood Street, which provides advice and support for carers in Swindon. I would like to receive an information pack from Focus.
Important Disclaimer: Please note that any information submitted using this form will be sent to the Practice by an unencrypted e-mail message. This means that someone else outside the Practice could possibly access and read it. Please contact us if you would like to find out about other ways to send us this information.

* Mandatory field

If you would prefer to contact the Carers Centre directly their details are:

Swindon Carers Centre
1 Wood Street
Swindon SN1 4AN
Tel: 531133