Your details (please only complete this form if you think you are an unpaid carer)

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* 1. What is your name?

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* 2. Please use the drop down menu to select which GP practice you are currently registered with as a patient?

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* 3. What is your email address? (If you don't have an email address please insert "NA" in the answer box)

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* 4. What is your mobile phone number? (If you don't have a mobile number please insert "NA" in the answer box)

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* 5. What is your landline phone number if you have one (e.g. 0151........)? (If you don't have a landline number please insert "NA" in the answer box)

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* 6. What is your date of birth?

Date of birth

Date

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* 7. What is your address?

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* 8. Carers Information Pack. As an unpaid carer, by completing this form, you will receice a Carers Information Pack and a registration form to register with the Wirral Carers Health and Wellbeing service that is delivered by Wirral based charity WIRED. Please indicate how you would like to receive your Carers Pack by choosing one of the options below. (Carers Packs normally arrive via text, email or post within 7 days after completing this form)

By text message - if you select this option, you will receive a text message with a clickable link that will allow you to download the Carers Pack to your phone, you can access the clickable link as many times as you want. With this option there is also the opportunity to register with the WIRED Carers Health and Wellbeing Service instantly by completing an online registration form.

By email - if you select this option, you will receive an email with a Carers Pack attached to the email that you can access. If you retain the email you can access the Carers Pack as many times as you want, there will also be the opportunity to register with the WIRED Carers Health and Wellbeing Service instantly by completing an online registration form. Additionally with this option its possible to print off the Carers Pack and the WIRED registration form and post it back to WIRED

By post - if you select this option, you will receive a hard copy Carers Pack and WIRED Carers Health and Wellbeing Service registration form through the post with a prepaid envelope to return the completed registration form at no cost to yourself.

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* 9. Consent required from you - Please click the box below to confirm that you give consent for;

WIRED to share the information within this form with your GP practice

For your GP practice to use this information you identify you on their records as a carer

For WIRED to store and process the information in this form to enable WIRED Carers Health and Wellbeing Service to contact you.

I give my consent