I have care support If you receive support from a friend, relative or paid professional please let us know, so that we can involve them appropriately in your care.Full NameDate of Birth Optional DD slash MM slash YYYY Email Responses we send will go to this email addressTelephone Number OptionalAddress, including postcode OptionalWhat relation to you is the carer? OptionalIs the person who cares for you a patient at this Practice? Yes Optional No (please inform the person you care for that we have their details on your record) Optional How much would you like your carer involved in your care? Join you at appointments Optional Discuss your treatment Optional Discuss your medication Optional They have power of attorney – finance only Optional They have power of attorney – health & social care Optional Consent We collect personal information when you enquire. We will use this information to provide the services requested and maintain records. We will not share your information for marketing purposes with any other companies. For more information explaining how we use your information please see our Privacy Policy
