Your accessibility needs | The Beeches Medical Practice

Your accessibility needs form

We want to get better at communicating with our patients:

We want to make sure you can read and understand the information we send you. If you find it hard to read our letters or if you need someone to support you at appointments, please let us know.
We want to know if you need information in braille, large print or easy read. We want to know if you need a British Sign Language interpreter or advocate.
We want to know if we can support you to lipread or use a hearing aid.

Please fill in the form below to tell us about your requirements.

Fields marked with a red asterisk * are compulsory. By using this form you will be sending information about yourself across the internet. Whilst every effort is made to keep this information secure, you should be aware that we cannot offer any guarantees of absolute privacy. Personal information retained on this system is treated as confidential.

Title *

Name *

First

Middle

Last

Date of birth *

Current home address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Home telephone number *

Mobile telephone number

Communication requirements *

Please tell us what communication requirements you have (.e.g. braile, large print, etc.)

Name