Register as a Carer Form

The definition of a carer – those aged under 65 who are in receipt of a carer’s allowance, or those who are the main carer for an elderly or disabled person whose welfare may be at risk if the carer falls ill.

Registering as a Carer

Your Details

Please complete this form if you are caring for someone. Once you are added to our list of Carers we will know about your busy life as a Carer, which can affect your health. We can also try and be flexible with appointments etc.

Title

Mr
Mrs
Miss
Ms

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of Birth

Telephone/Mobile Numbers

Email Address *

Confirm Email

Details of the person you are caring for

Title of person being cared for

Mr
Mrs
Miss
Ms

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Date of Birth

What relation to you is the person you are caring for?

Is the person you care for a patient at Scotch Quarter Practice? *

IMPORTANT PATIENT NOTICE:

We are changing our clinical IT system between the dates of: 4th December and 11th December.
Please ensure you have ordered your prescriptions ahead of these dates. Please note there may be limited appointments available during this time.
We apologise for any inconvenience this may cause.

Scotch Quarter Practice

Carrickfergus Health Centre | Taylor's Avenue | Carrickfergus | Co. Antrim | BT38 7HT | Tel: 028 9331 5955

Your Details

Details of the person you are caring for

Scotch Quarter Practice

Surgery Hours

Policies

IMPORTANT PATIENT NOTICE: