GP Surgery – Carer Identification Form (To be completed by or on behalf of the carer) 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.1. Your Details (The person providing care)Full NameDate of Birth DD slash MM slash YYYY Address Street Address Address Line 2 City/Town ZIP / Postal Code 2. Patient details (The person being cared for)Full NameDate of Birth DD slash MM slash YYYY Relationship to the carer:Is the patient registered at UHS? Yes No 3. Nature of Care ProvidedWhat 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: Please specify what other care you provide to the patient:4. Carer Support NeedsDo you feel you need support in your caring role? Yes No Not Sure If yes or unsure, what kind of support would be helpful? (Tick any that apply) Emotional support or someone to talk to Advice about benefits or financial help Help with taking a break from caring (respite) Information about local services or support groups Support with managing your own health Other: If other, please specify what other kind of support would be helpful.Would you like someone from the surgery to contact you to discuss support? Yes No 5. ConsentConfirmation 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. SignatureDate of Completion DD slash MM slash YYYY