Carers Form

Are you a carer?

A carer is a person of any age, including children, who provides unpaid support to a partner, relative, friend or neighbour who could not get by without their help. This could be due to old age, frailty, disability, a serious health condition, mental ill health or substance misuse. Parents of children who are disabled or who have a serious health condition are also considered to be carers.

As a Practice we would like to support you. Please complete the form below and pass it to one of our Reception team.

Carers Details

First Name:

Surname:

Home Address:

Postcode:

Date of Birth:

Email Address:

Telephone Number:

Details of Person(s) Being Cared For

First Name:

Surname:

Home Address:

Postcode:

Date of Birth:

What relation is the person you care for?

Is the person you care for a patient at Cowdenbeath Medical Practice?

Fife Carers Centre

With your permission we can pass your details to Fife Carers Centre who will assess your needs and provide you with any support that you may require.

This is a chance to talk about your needs as a Carer and the possible ways help could be given. It also looks at the needs of the person you care for. This assessment is free of charge.

For further information and contact details please visit the Fife Carers Centre website: www.fifecarerscentre.org

I would like my details passed onto the Fife Carers Centre

I would like a support worker from Fife Carers Centre to contact me

I would like Fife Carers Centre to add me to their mailing list

Consent

This form collects your name, date of birth, email and other personal information along with certain medical details. This is to confirm that you are a registered patient with Cowdenbeath Medical Practice to allow the Practice team to contact you to discuss the management of your medical care and also to update the records that we hold. For further information on how we protect and manage your submitted data please read our privacy policy.

Do you consent to the Practice collecting and storing your data from this form

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Cowdenbeath Medical Practice • 173 Stenhouse Street, Cowdenbeath, Fife, KY4 9DH.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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