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:

Due to the extreme red weather warning in place. Unfortunately we will be unable to open at 2pm today, 24 January, due to a power failure and phone lines being down.

While the surgery is still without power and phones, a GP will be on site from 4pm for emergencies.

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: