Reasonable adjustments request

Section

Do you have an impairment that has a substantial and long-term adverse effect on your normal day-to-day activities?

For example, you may have difficulty walking, seeing, hearing or remembering things.

Do you require a reasonable adjustment to help you access health and care services?

For example, you might need information in large print, extra time for appointments, or help to move around the clinic.

Consent to share

We would also like to ask for your consent to share information about your reasonable adjustments with other NHS and social care teams. This will help them understand what reasonable adjustments you may need when you see them.

Consent

Yes – I consent for my Reasonable Adjustment data to be uploaded to the NHS Spine (shared record)

No – I decline consent for my Reasonable Adjustment data to be uploaded to the NHS Spine (shared record)

Your privacy is important to us. All information provided will be handled in accordance with our privacy policy and relevant data protection laws. If you have any questions or need assistance with this form, please contact our practice. Thank you for helping us make our healthcare services more accessible to everyone.

Tell us whether you accept cookies

Reasonable adjustments request

Section

Consent to share