Accessing Information and Support

Name

Date of Birth

How would you describe your Disability/Sensory loss?

Are you housebound?

Yes

What can we do at the surgery to help improve the information we provide and is there any communication support you need us to arrange?

e.g. large print, best time to attend appointments, text messaging, email, summary of practitioners advice?

Do you consent to us using preferred method of contact?

Yes

Do you require support in obtaining information of other local services outside the surgery?

Do you have access to a computer?

Yes

For example, you can access NHS.UK and select Care and Support to access specialist advice and local support groups. Or you can ask the Receptionist to help you.

Do you have a Family Member, Friend, Carer who attends appointments with you?

Yes

Name

This person MUST Consent to their details being added to your record.

Relationship

Consent Obtained

Yes

Sharing Your Health Record We share your medical information with other health and social care providers involved in your care, unless you ask us not to. Please refer to our Privacy Notice on our web site. Or ask our Reception Staff for a copy.

Is there any other information you would like us to know about? Optional

Date

Accessing Information and Support

Thank you for helping improve our services