The Barn Surgery: 01747 824201
Peacemarsh Surgery: 01747 834330
Out of Hours: 0845 600 10 13
NHS Direct: 0845 46 47
Gillingham Medical Practice 
CARERS IDENTIFICATION FORM

Do you look after someone who is ill, frail, disabled or mentally ill?

If so, you are a carer and we would like to support you.
Please print and complete this form and hand it in to reception.

Your details
Name:
Date Of Birth:

Address:
Post Code:
Telephone Number:
Any relevant information:
Details of the person you look after
Name:
Date Of Birth:

Address:
(if different from above)

Post Code:

Telephone Number:
(if different from above)

GP Details:
(if different from your own)

Thank you for completing this form.
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Last updates applied: Thursday, July 23, 2009