Communication requirements

Section

What is the easiest way to contact you? *

Contact the patient directly

Contact the carer

Other

Carer Contact Details

Carers Name: *

Carers Phone Number: *

Carers Email Address: *

Please provide the easiest way to contact you: *

Please specify other:

I require written information in at least font:

Size 20

Size 24

Size 28

Have you got any visual difficulties?

Have you got any hearing issues? Do you use any hearing aids?

Can you lip read?

Yes

No

Do you use a guide dog?

Yes

No

Do you require an interpreter?

I require an interpreter for my main spoken language

I require a sign language interpreter

I have my own interpreter

What is your main language?

Interpreter Contact Details

Interpreters Name:

Interpreters Phone Number:

Interpreters Email Address:

Do you have any issues with your speech, reading or writing?

Do you use any other forms of communication methods/aids?

Do you have any learning disabilities?

If you need anything that is not on the list above, please tell our receptionist when you come in for your next appointment and we will do our best to meet your needs.

Tell us whether you accept cookies

Section

Carer Contact Details

Interpreter Contact Details