Accessible Information and Reasonable Adjustments

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
Processing
Accessibility questions
Do you have a disability or impairment? : *
Examples include hearing impairment, visual impairment, learning disability, memory loss, autism spectrum disorder, mobility issues, physical disability etc.
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 need a longer appointment, need an audible or visual alert when attending the practice, use a hearing aid, lip reads etc.
Do you need information in a format other than the standard written format? : *
Examples include verbally, in large print etc.
Do you need any other reasonable adjustments?: *
Examples include need a longer appointment, use a mobility scooter and need to be seen on the ground floor, needs appointments at start or end of day, requires low light etc.
Are you happy for this to be shared with other organisations in the NHS and social care that will be involved in your care?: *
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 or by telephone only, contact via your carer only etc.
Carer Contact Details

If you need us to only contact you via your carer please fill in carer details below:

Is this your main carer?: *
Is this a professional carer?: *
Have you been diagnosed with dementia? : *
   
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

If you are an unpaid carer we would like to add your name to our register of carers. Once you are registered, we can offer you more help and advice like health checks, flu injections and appointments to fit in with your caring role where we can.

If you are happy for us to add you to our register of carers tick 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 LinkedIn YouTube