GP Carer's Prescription

Carers look after family, partners or friends in need of help because they are ill, frail or have a disability. The care they provide is unpaid. Carers UK Definition

COVID NOTICE

Primary care are being asked to identify and share with the vaccination services their lists of patients in cohort 6 which include

1. Younger adults in long stay in-patient, nursing and residential care settings

2. Adult carers - those who are eligible for a carers allowance and / or those who are the sole or primary carer of a elderly or disabled person who is at increased risk of Covid19 mortality and therefore clinically vulnerable. Identifying carers relies on accurate GP coding, please flag unpaid carers that meet the above definition to ensure they are invited for vaccination.

3. Adults aged 16 to 65 yrs in an at risk group (based on their medical history)

The full details of the eligible health conditions in Cohort 6 are in the Green Book which can be found here

Carer Information

Please fill in this form to refer the Carer for a Carer's Prescription Service. In the section below please complete only the Carer's Details. Please record if the Carer declines (in which case no further data is required)

IMPORTANT PLEASE READ THE FOLLOWING STATEMENT TO THE CARERS OR THE YOUNG CARER

The personal information you provide in this form will be shared with Surrey Independent Living Council and/or Action for Carers (Surrey). They will use the information to contact you to discuss the support and assistance they can provide to you via the Carer’s Prescription Service.
They will ensure that all personal information on this form is kept secure and processed only in accordance with current data protection legislation. You can contact them if you have any queries about how they use your personal information.

Please tick one of the boxes below to confirm that agreement has been obtained or declined to share carers information with Surrey independent Living Council and Action for Carers Surrey
*

Carer agreed they would like a GP carer’s prescription

Carer did not agree to a GP's carers prescription

If the Carer does not want a GP prescription we are unable to process the precription in accordance with current data protection legislation. PLEASE DO NOT SUBMIT THIS FORM IF YOU SEE THIS MESSAGE

Fair Processing Notice

I declare that the carer or the young carers family has received a copy of the Fair Processing Notice *

Yes

No

Please click here to download a copy of the Fair Processing Leaflet

Carer's Details

Carer's First Name *

Carer's Last Name *

Sex of Carer 🛈

Contact Telephone Number *

email address

Preferred method of communication

Date of Birth * +

NHS Number *

Carer Address *

Referral Date * +

What is the primary condition the carer is caring for? *

Please tick here if the Carer is caring for someone in end of life circumstances

Yes

Are there any other Carers in the household (details of other carers will be picked up as part of the assessment process?

Yes

Reason for Referral 🛈

Young Carer's (5 to 18 years)

Please tick here if parental consent is required by your organisational policy . For more information please reference the Gillick Competency and Fraser Guidelines.

Yes

No

Are you referring a young carer

Yes

No

Is the young carer Gillick Competent?

Yes

No

Do the family wish to have a service

Yes

No

GP Practice Details

GP Practice Name *

GP Practice NHS Code *

Contact Telephone Number *

Name of Referring Practioner *

Position *

CCG Area *

email address *

Carer's Prescription (Type of Service Needed)

As part of our COVID response, we have two distinct additional offers to carers:

New Service to support carers during COVID 19 SUCH – This is a series of FREE 45 minute webinars which are available to carers. The sessions will help carers in creating a ‘Safer Environment’ during the pandemic, with the aim of reducing infection rates. Please check the carer has access to the internet on a device before ticking the COVID 19 box below. The internet access may be through home internet or mobile internet.
NHS Carer Identification Letter (COVID 19) - This is a letter which is given to carers to identify them as a carer and to help them maintain their caring role in event of restriction of population movement by Government because of COVID 19 infection rates. The letter will be sent in hard copy or via email from Action for Carers (Surrey) when this form is processed.

Type of Service (s) requested 🛈

	Tick the item(s) below
Carer's Information Pack	Tick the item(s) below
Adult Carer's Support	Tick the item(s) below
Young Carer's Support	Tick the item(s) below
GP Carer Break	Tick the item(s) below
NEW Service -to support carers during COVID19 SUCH	Tick the item(s) below
NHS Carer Identification Letter (COVID 19)	Tick the item(s) below

Other information

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