Your Access and Care Needs

Please use this form to let us know about any care or access needs you have, so that we can better help you.

Your Access and Care Needs

Your Access and Care Needs

About you

Please use this date format: DD/MM/YYYY.
Any responses we send will go to this email address.

Your Language Needs

What is your main language?
If English is not your main language do you need an interpreter for your consultations?

Your Assistance Needs

Do you have any impairments or disabilities? (e.g. Hearing, Sight, Speech, Learning, Neurological, Mental or Physical)
If you have an impairment or disability…
Do you need us to contact you in a specific way (e.g. text relay, phone, text message, etc.)?
Do you need us to send you information in an alternative format to standard print? (e.g. large print, Makaton, etc.)
Do you need us to provide you with any communication support? (e.g. hearing loop, sign interpreter, etc.)
Do you use an Assistance Dog?
Do you use a wheelchair or mobility scooter?
Our Surgery is located in a historical building that does not have a lift/elevator. Do you require a ground floor room for your consultations?

Your Carers and Emergency Contacts

If you have a Carer or Key Worker to support you, please provide their contact details:
Do you consent to us sharing relevant information about your health to your Carer/Key-worker?

Your Emergency Contacts

In event of an emergency:
Can we discuss relevant medical information about you with this person in an emergency?
Your next of kin (if different):
Can we discuss relevant medical information about you with this person in an emergency?

Are you a Carer for another person?