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Carer Identification Form

Carer Identification Form

Carer Identification Form

Why this form?

If you look after someone who couldn’t manage without your help due to illness, disability, mental health needs, or addiction, you are a carer. Letting us know helps us support you better.

(To be completed by or on behalf of the carer)

Your Details (The person providing care)

Full Name *

Date of Birth *

Address *

Post Code *

Patient Details (The person being cared for)

Full Name

Date of Birth

Relationship to the carer

Is the patient registered at UHS?

Yes No

Nature of Care Provided

What care do you provide to the patient?

Personal care (e.g. washing, dressing)

Practical help (e.g. shopping, cooking)

Medication support

Managing appointments or finances

Emotional Support

Other

Carer Support Needs

Do you feel you need support in your caring role?

Yes

No

Not Sure

Would you like someone from the surgery to contact you to discuss support?

Yes No

Consent

Confirmation and Consent *

I confirm that I am the carer of the patient named above

I consent to my details being added to the patient's records, if they are also registered at the University Health Service

I give permission for the GP surgery to contact me regarding carer support

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Page last reviewed: 10 November 2025
Page created: 10 November 2025

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