Carer Registration Form

Please add my name to the Carers record that is held by the Bovey Tracey & Chudleigh Practice.

Please select the practice location most relevant to this Online Form submission:

Your (Carer's) Details

Name

Date of BirthPlease enter Date of Birth as DD/MM/YYYY

Address

Best Contact Phone NumberPlease put the number we are most likely to be able to contact you on if required.

Additional Contact Phone Number

Details Of The Person You Care For

Name

Date of Birth

Address

Your relationship with this persone.g. spouse/child/parent

Their doctor

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Riverside Surgery • Le Molay-Littry Way, Bovey Tracey, Devon, TQ13 9QP.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.

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