Accessibility Needs

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)

All questions marked with a * are mandatory

Personal Details
Please double check you've entered the correct email address
May be used to identify you
Processing
Accessibility Questions
Do you have a need that requires us to contact you in a certain way?: *
Examples include using the text relay service, by letter only, telephone only or contact via carer only
Do you have a carer that all contact needs to go through?: *
Do you need professional communication support or an interpreter?: *
Examples include carer support, British Sign Language Interpreter, note taker, etc.
Do you need support to communicate or use a communication aid?: *
Examples include needing a longer appointment, audible or visual alert, lip reading or using a hearing aid
Do you need information in a format other than the standard written format? : *
Examples include verbally, in large print etc.
Processing
Additional Questions
Are you a parent of a dependent child?: *
Are you a carer?: *
Child 1
Do you have additional dependent children?: *
Child 2
Do you have additional dependent children?: *
Child 3
Do you have additional dependent children?: *
Child 4
Do you have additional dependent children?: *

We will contact you to take further details

Caree 1
Are you the main carer?: *
Has the patient you care for been diagnosed with dementia?: *
Do you care for additional people?: *
Caree 2
Are you the main carer?: *
Has the patient you care for been diagnosed with dementia?: *
Do you care for additional people?: *

We will contact you to take further details

Carer Register

As an unpaid carer, we would like to add your name to our register of carers. Once registered, we can offer you more help and advice like health checks, flu injections and appointments to fit within your caring routine.

If you are happy for us to add you to our register of carers please let us know below. We will then write to the person you are caring for because they also need to let us know that they are happy for you to be registered as their carer on their medical record.

Can we add you to our register of carers?: *

Privacy Consent

Processing

There appears to be a problem loading the form, please refresh the page.
If the error persists please contact us.

Facebook Instagram Twitter