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Dear Patient

We are updating your records and we are enquiring if you receive help from a carer and if you have a next of kin.

We would appreciate if you could complete the below form to help us ensure your records are up-to-date and to be able to provide you the right support and advice.

Failure to respond by [DATE[] means we will assume you do not have someone caring for you.

If you would like to talk to someone about this, please call 020 3474 6730 and ask to speak to Cory, the Carer's Administrator.

Thank you

Amersham Vale Practice

Personal Details
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Carer Definition

What is a carer?

Definition of a carer - A carer is anyone who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction and cannot cope without their support. The care they give is unpaid. 

Who Looks After You?
Next Of Kin

It is your responsbility to ensure that the details for your Next of Kin (NOK) or emergency contact are kept up-to-date. You can do this anytime by submitting an admin KLINIK form or at your next appointment.

Carers Support

If we can help you, we will send you or call you with information in regards to your questions.

We can refer you and your carer for social prescribing who can offer you further support and advice.

What is Social Prescribing?

If you are interested in social prescribing, please mention it above.

Note: If you have internet access, download and use the ASKFIRST APP, where you will be able to self-refer to many social prescribing opportunties via the app (also available via a browser).

Today's date

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.


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