Skip to main content

Cookies on the The Waterloo Practice website

We've put some small files called cookies on your device to make our site work.

We would also like to use google translate cookies and analytical cookies to understand how our site is used and improve user experience. Analytical cookies send information to Google Analytics.

Let us know your preference. We will use a cookie to save your choice. Before you make your choice you can read more about our cookie policy.

You can change your cookie settings at any time using our cookie policy.

The Waterloo Practice

Home
Easy Read Guides
Opening Hours
COVID-19 Information
Appointments
Prescriptions
Blood Test Results
New Patients
Online Forms
Patient Participation Group
Online Services
Kirklees Help & Support
Health Advice
Cervical Screening Information
Our Staff
Contact Us
PATCHS
Online Services
Appointments
Prescriptions
Blood Test Results
New Patient Registration
Online Forms
Patient Group
Fit Note Request

PATCHS
Online Services
Appointments
Prescriptions
Blood Test Results
New Patient Registration
Online Forms
Patient Group
Fit Note Request

Home
Easy Read Guides
Opening Hours
COVID-19 Information
Appointments
Prescriptions
Blood Test Results
New Patients
Online Forms
Patient Participation Group
Online Services
Kirklees Help & Support
Health Advice
Cervical Screening Information
Our Staff
Contact Us

Home
Communication / Information Needs

Communication / Information Needs

Communication / Information Needs

Complete this form if you have a disability, impairment, or sensory loss to ensure you receive information from us in a format you can use and understand. This information will also help us ensure you receive any communication support you need.

Patient Information

First Name *

Surname *

Date of Birth *

Address *

Do you have any communication needs (language, vision or hearing) *

Yes No

Do you have a learning disability? *

Yes No

If you have answered yes above, as a result of your communication needs / learning disability do you require contact by (tick all that apply)

Email

Letter

SMS text message

Telephone

Text relay

Via a carer

Via telephone interpreting line

Do you require your information (tick all that apply)

In a bigger font

Deaf-blind communicator guide

Braille

Easy read

Electronic audio format

Makaton

Moon alphabet

Lip speaker

Loud verbal communication

Manual note taker

Speech to text reporter

Require a third party to read out written information

Do you have difficulties in any of the following (tick all that apply)

Vision

Hearing

Language

Reading

Writing

Do you use a communication aid

Yes No

Is there anything else you feel we need to know about your communication needs?

Oops... There was an error contacting reCAPTCHA, Please try again.

This form is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.

Page last reviewed: 14 August 2020
Page created: 30 July 2020

Further Information

Home
Vacancies
Kirklees Help & Support
Primary Care Network - Tolson Care Partnership
Accessible Information
Data Privacy
Update Your Patient Record
Carers Advice
GP Earnings
Practice Policies
Creating a Single CCG for Kirklees
Services

Add Footer Link

Sign in

© 2025 Built by My Surgery Website
Accessibility
Cookie policy
Your data
Site map

Translate this website with google