Accessibility

How would you prefer to communicate with us? *

Speech

In writing

Makaton

British sign language (BSL)

Language interpreter

Through a carer or family member

If you need an interpreter, please let us know here which language

How would you like to get information from us?

Email

Text message/SMS

Letter

Phone call

TelephoneText relay

Large font letter

Via a carer

Easy Read Letter

Via a family member

If you need us to communicate via a carer and/or family member please let us know their name and telephone number here:

Do you have any other needs? Pick as many as you need to. *

Quiet areas due to noise intolerance

Wheelchair at the surgery

Hearing loop

Longer appointments

Appointments at set times of the day

None

If you need appointments at a certain time of day please let us know here

Please tell us is there is anything else which could help you access the surgery better

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA *

I consent to the practice collecting and storing the information on this form

Can we share this information with other NHS organisations that might be involved in your care through your electronic health record. *

Yes

No

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