Register as a Carer Carer's detailsName First Last Address Street Address City State / Province / Region Postcode Date of Birth Day Month Year Contact numberEmail Details of person being cared forName First Last Address Street Address Address Line 2 City Postcode Date of birth Day Month Year What is your relationship to the person you care for?Is the person you care for a patient at The Lodge Surgery? Yes No ConsentTHIS 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. I consent to the practice collecting and storing my data from this form.