Carers - Rutland Lodge Medical Practice

Carer details

Title

Mr
Mrs
Miss
Ms

First name(s)*

Surname*

Address*

Post Code*

Date of birth*

Email address*

Enter Email Confirm Email

Telephone*

Details of Person Being Cared For

Title

Mr
Mrs
Miss
Ms

First name(s)*

Surname*

Address

Post Code

Date of birth

What relation is the person you care for?

Is the person you care for a patient at this surgery?*

Yes
No

Consent*

I agree to the privacy policy.

Please note that no medical information or questions will be responded to. The data you supply on this form will be stored on our website, which is hosted by a third party, until it has been processed by the practice. The data will be used lawfully, in accordance with the Data Protection Act 2018, which 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. The practice privacy policy can be viewed on this website.