Are you a Carer? Almond Road Surgery Carer’s Policy – Identification formCarers Identification FormDo you look after a family member or friend who is unwell, disabled or frail? If so please complete this form. Once you are added to our list of Carers, we will have an insight into your busy life as a Carer and it’s potential affect on your health. We can also try and be flexible with appointments etc. as we will know about your caring commitments. Identifying yourself as a carer, will enable us 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 DetailsName First Last Date of Birth DD slash MM slash YYYY NHS Number Find your NHS numberAddress Street Address Address Line 2 City Postcode Phone NumberIdeally a mobile phone numberEmail Details of the person you provide care forName First Last Date of birth DD slash MM slash YYYY NHS Number Find your NHS numberAddress Street Address Address Line 2 County Postcode Telephone Number Practice Registered at & GP's Name What relation is the person you care for? Details of the Care you provide:Is the person you care for a patient at Almond Road Surgery? Yes No Please pass my details to the local Carer Support Services Yes No I consent to you referring me to Adult Social Care for an assessment Yes No SignatureDate MM slash DD slash YYYY