Carers - HEMC

A carer is a person who is in receipt of a carer’s allowance, or who is the main carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill.

If you feel you are a carer, please complete the form below and send it to us by email or drop it back to reception.

If you have a carer, please let us know and we will add this to your medical record.

Carer Identification Form

"*" indicates required fields

What is a carer?

A person who is in receipt of a carer’s allowance, or who is the main carer of an elderly or disabled person whose welfare may be at risk if the carer falls ill.

By identifying yourself as a carer, we will be able to support you and signpost you to the support services available to you as a carer. If you consent, we will also refer you to Adult Social Care for an assessment; they will identify your needs and provide further support to you as a carer.

Carer's Details

Name*

First Last

Date of Birth*

NHS Number Optional

Address*

Street Address Address Line 2 City Postcode Country

Email Address

Enter Email Optional Confirm Email Optional

Contact Number*

Details about the person you care for

Name*

First Last

Date of Birth*

NHS Number*

Address*

Street Address Address Line 2 City Postcode

Contact Number*

GP and Practice*

Details about the care you provide

Please specify what care you provide*

Consent

I consent to you referring me to Adult Social Care for an assessment. Optional

Please pass my details to the local carer support services. Optional

Signature*

(Please enter you full name)

Name Optional

This field is for validation purposes and should be left unchanged.