Register carer details

DORDON & POLESWORTH GROUP PRACTICE

CARERS FORM

Do you look after someone who is ill, frail, disabled or mentally ill? If so, you are a carer.  The Practice is interested in identifying carers, especially those people who may be caring without help or support.  We know that carers are often “hidden” looking after a family member or helping a friend or neighbour with day to day tasks and may not see themselves as a carer.

We feel that caring for someone is an important and valuable role in the community, which is often a 24-hour job that can be very demanding and isolating for the carer.  We further believe carers should receive appropriate support by way of access to accurate information on a range of topics such as entitlement to benefits and respite care and not least, a listening ear when things get too much.

As a Carer, you are also entitled to have your needs assessed by Social Services. The Assessment is a chance to talk about your needs as a carer and the possible ways help could be given. It also looks at the needs of the person you care for.

Please complete this form and if you are agreeable, we will pass your details to Social Services to have your needs assessed.

 

1Your details

2Details of the person you look after

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and TLS (using a 2048 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified - the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted and secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

© Dordon and Polesworth Group Practice 2017
Dordon Surgery - 162 Long Street, Dordon, Tamworth, Staffordshire, B78 1QA
Polesworth Surgery - High Street, Polesworth , Tamworth, Staffordshire, B78 1DU
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