Communication support patient details

Who are you completing this form for?

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name?

First name

Last name

What is your date of birth?

For example, 31 3 1980

Day

Month

Year

What is your sex?

As recorded on your medical record

Male

Female

Other

What is your postcode?

The one used to register with your GP

What is your phone number?

What is your email address?

Anyone else with access to your email account may see responses sent to you

There are medical reasons why I need additional information and communication support at this practice.

Please state your preferred language:

Other – Please specify:

Please tick all that apply to you:

I need help with booking appointments

I need help during consultations e.g. from a British Sign Language Interpreter or translator

I require large format for letters or written communications

I need test results and written communication emailed to me so I can use assistive technology e.g. screen reader

I need to use ‘Speech to Text’ relay

Please give details:

For us to help you receive the best medical care, do we have your consent to share this information with other health and social organisations if necessary (i.e. hospital or social services)?

Yes

No

Do you have a carer who has completed a carers’ card for the practice?

Yes

No

Is there anyone you would like to have access to your medical records i.e. appointments and test results?

Yes

No

If yes, a consent form will need to be signed by them at your next appointment with a doctor. Please ask the person to attend with you.

Are there any other ways we can help you? Please give details:

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