If you have any information or communication needs relating to a disability, impairment or sensory loss please tell us what support or format would help you. Please answer each question to the best of your ability. Tell us about what you need support with, and how we can help(Required) I have difficulty hearing or understanding speech I may need information to be provided in a different format I use a communication aid I need an interpreter I may need more time to process information Something else What kind of support would help you if you have difficulty hearing or understanding speech?(Required)Which format or formats work best for you?(Required)If you use a communication aid, is there anything we can do to support you when communicating with us?(Required)What type of interpreter do you need?(Required)How can we best support you if you need more time to understand or process information?(Required)What is your main communication or information need, and how can we support you?(Required)If you have any other information or communication needs, tell us about them here.If there are ways that we can support you please include that information too.What is your postcode?(Required)Are you able to provide your NHS number? This is the best way for us to locate your records to add this information Your NHS number is a 10-digit number. You can get it from: any NHS letter or prescription the NHS app your GP surgery online via the NHS ‘find you NHS number’ service. If you’re not able to provide your NHS number we’ll need some other information to make sure we can identify you.Are you able to provide your NHS number?(Required) Yes No Insert your NHS number?(Required)What is your full name?(Required)What is your date of birth?(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please provide an email address or phone number that we can contact you on.(Required)We will only use this if we have trouble locating your care record.Consent(Required) I understand and agree to this information being used to support my careThank you for sharing this information with us.We will use it only to update your care record and to make sure we understand how best to communicate with you. Your information will be handled securely and in line with our privacy policy the NHS Accessible Information Standard, and the Equality Act 2010.
