Reasonable adjustments form

Please fill in the form below to let us know what we can do to help you access services at the surgery.

You may need to ask a carer, friend or relative to help you.

If you would rather speak to someone, please phone or visit the surgery. We can then write your requirements into your care record.

Instagram

This field is for validation purposes and should be left unchanged.

Patient name(Required)

First name(s) Last name

Patient NHS number (if known)

Daytime telephone number(Required)

Date of birth(Required)

Address(Required)

Email(Required)

Enter Email Confirm Email

What we can do to help you access services at the surgery?(Required)

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help