Accessible Information Standards

The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or sensory loss can receive, access and understand information, for example in large print, braille or via email, and professional communication support if they need it, for example from a British Sign Language interpreter. This applies to patients and their carers who have information and / or communication needs relating to a disability, impairment or sensory loss. It also applies to parents and carers of patients who have such information and / or communication needs, where appropriate. Individuals most likely to be affected by the standard include people who are blind or deaf, who have some hearing and / or visual loss, people who are deaf blind and people with a learning disability. However, this list is not exhaustive.

Last Updated: 28/07/2020

Your Details

First Name *

Surname *

Date of Birth *

Phone Number

Your Needs

Do you have communication needs? *

Do you need a format other than standard print? *

Yes No

Do you have any special communication requirements? *

Yes No

How do you prefer to be contacted? *

What is your preferred method of communication? *

How would you like us to communicate with you? *

Can you explain what support would be helpful? *

What is the best way to send you information?

What communication support could we provide for you?

Carer Details

Please complete all of the questions in this section if you have a carer.

If you have a carer do they need communication assistance?

Yes No

If ‘Yes’ what is your Main Carer’s name:

Do you consent to the practice contacting your main carer regarding your care?

Yes No

What is the best way to contact them?

Declaration

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

I consent to the practice collecting and storing my data from this form.

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Accessible Information Standards

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