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The Waterloo Practice

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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

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.

Last Updated: 14/08/2020

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?

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Further Information

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