Carer Registration Posted on: 22/05/202522/05/2025 Register as a Carer Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Address Street Address Address Line 2 City Postcode Date of Birth Day Month Year Contact numberEmail Enter Email Confirm Email Details of person being cared forName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Address Street Address Address Line 2 City Postcode Date of birth Day Month Year What relation is the person you care for?Is the person you care for a patient at Bridge & Monkseaton Medical Practice? Yes No If no, please let us know where they are registered? OptionalHow many hours a week, on average, do you provide care?Which of these tasks do you undertake in your role as a carer? Tick all that apply Practical tasks, such as cooking, housework and shopping Physical care; such as lifting, helping on stairs or with physiotherapy Personal care; such as dressing, washing, helping with toileting needs Managing finances, collecting benefits and prescriptions Administering medication Emotional support Interpreting, due to a hearing or speech impairment or because English is not first language Are you a member of, or have you used any, carer support organisations? Yes No If yes, which ones? OptionalDo you feel you are taking care of your physical wellbeing adequately? Yes No Do you feel you are taking care of your mental wellbeing adequately? Yes No Is there any other information that you feel the practice should be aware of? OptionalThis form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form.
Register as a Carer Name Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Address Street Address Address Line 2 City Postcode Date of Birth Day Month Year Contact numberEmail Enter Email Confirm Email Details of person being cared forName Dr.MissMr.Mrs.Ms.Mx.Prof.Rev. Title First Last Address Street Address Address Line 2 City Postcode Date of birth Day Month Year What relation is the person you care for?Is the person you care for a patient at Bridge & Monkseaton Medical Practice? Yes No If no, please let us know where they are registered? OptionalHow many hours a week, on average, do you provide care?Which of these tasks do you undertake in your role as a carer? Tick all that apply Practical tasks, such as cooking, housework and shopping Physical care; such as lifting, helping on stairs or with physiotherapy Personal care; such as dressing, washing, helping with toileting needs Managing finances, collecting benefits and prescriptions Administering medication Emotional support Interpreting, due to a hearing or speech impairment or because English is not first language Are you a member of, or have you used any, carer support organisations? Yes No If yes, which ones? OptionalDo you feel you are taking care of your physical wellbeing adequately? Yes No Do you feel you are taking care of your mental wellbeing adequately? Yes No Is there any other information that you feel the practice should be aware of? OptionalThis form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the NHS. Please read our Privacy Policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form.