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Patient Group

It’s important that everyone who works here at Cippenham Surgery knows you are a carer so that we can offer you help and support if you need it. Anyone who looks after a friend or family member who cannot manage without them, and is unpaid, can register. This includes carers under the age of 18.

If you are a carer, please complete this form below.

Registration Form

 
 
 
 
(by providing this number you are consenting to us contacting you by text if necessary)
 
Are you male or female?  
What age are you?  
Which of the following best describes your ethnic background?  
Please Specify  
How would you describe how often you come to the practice?  
 
 
Are you a parent/guardian of a child under 18 years of age?  
Do you consider that you have a disability?  

The information you supply us will be used lawfully, in accordance with the Data Protection Act 2018. The Data Protection Act 2018 gives you the right to know what information is held about you, and sets out rules to make sure that this information is handled properly.

Fields marked with an asterisk (*) are mandatory