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By submitting this professional referral, I confirm that the carer has given me consent to refer them to Care for the Carers, and they are aware that I am making this referral. The carer has agreed for the personal data contained in this referral to be shared with you. Care for the Carers will attempt to contact the carer within 5 working days of receiving the referral, and will acknowledge receipt of your referral if you provide your email address at the bottom of the form.
Surname*
Forename(s)*
Address line 1*
Address line 2
Address line 3
Address line 4 (Town)*
Address line 5 (County)*
Postcode
Main Telephone No.*
Email Address (Main)
Date of Birth
Gender
Ethnic Group
Sexual Orientation
Marital Status
Religious Group
Employed?
GP Surgery
What is the relationship of the person being cared for to the carer?*
What is the main health condition of the person being cared for?*
Carer’s main health issue or disability
Reason for Referral and Referrer Details
Reason for referral, any actions/referrals already completed, and Referrers name, organisation, and contact details*
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