Reasonable Adjustments

Communication

General Information

Please indicate if your have a Hospital Health Passport

Yes No

Do you use a Guide Dog?

Yes No

Do you use a wheelchair?

Yes No

Are you able to use Online Services?

Yes No

Reasonable Adjustments

Reasonable Adjustments might include support such as having longer appointments, waiting in a quiet area when attending for appointments, requiring either a female/ male clinician, needing home visits.

Do you need to let us know of any other reasonable adjustments to make your visit to the GP surgery accessible?

Do you consent to the information you have provided being shared with other organisations in the NHS and social care that will be involved in your care so that they are better able to understand your needs? *

Yes No

Patient Details

First Name *

Surname *

Date of Birth *

NHS number (if known)

Postcode *

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