Register a Carer - Tollgate Medical Centre

It is important that we know if you are a carer so that we can make sure you receive information, services and the help that is available. If you are a carer please complete this form.

Non-urgent advice:

Please read this form carefully and submit after completing.

Register as a Carer

Carer Details

Name

Date of Birth

Phone Number Optional

Email Address

Address

Street Address Address Line 2 City Postcode

Details of Person Being Cared for

Name

Date

Address

Street Address Address Line 2 City Postcode

What is your relationship to the person being cared for?

Is the person you care for registered at this surgery

Yes

I consent to the practice collecting and storing my data from this form.

This 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