Patient communication needs Accessible Information StandardsDo you have a disability, impairment or sensory loss and need to receive information in a way you can easily understand? If so we want to help you.We can offer Large Print, some information in Braille, secure online communication, assistance for patients with a hearing impairment, alternative languages and other support.If we can help please complete this form so we can make sure to record your needs and that you have access to information wherever possible in a format that you understand.Patient DetailsYour name* First name Middle name Last name Date of birth* DD MM YYYYAddressPost CodeMobile telephoneEmail Enter Email Confirm Email Your disability or impairmentPlease describe your disability or impairmentSharing your details*Can we share your record with other health professionals who are involved in your care (this will help them also to provide information that is suitable to your needs?)YesNoCarer*Do you have a CARER you would like us to record on your records?YesNoIs your carer our patient?Are they a patient here at our surgery?YesNoSpouse/Carer/Nominated person detailsName of Spouse/Carer/Nominated person First name Middle name Last name Date of birth of Spouse/Carer/Nominated person DD MM YYYYAddress of Spouse/Carer/Nominated personPost Code of Spouse/Carer/Nominated personTelephone number (land line) of Spouse/Carer/Nominated personMobile telephone of Spouse/Carer/Nominated personEmail of Spouse/Carer/Nominated person Enter Email Confirm Email Sharing informationDo you want us to share any of your medical information with the named person above?YesNoPhone messagesAre you happy for us to leave any phone messages for you with the above person?YesNoVisually impairedWe can provide some information on CD or direct you to other NHS resources’ where you can listen to information.Type sizeWould you prefer text to be in large print? If so please select a size below.No preference20 point24 point28 pointOther information about a visual impairmentPlease include any other information about a visual impairment you wish us to know about.BrailleThere is limited information available in braille but we will always so our very best to provide in this format or another suitable format. Please include any other information about braille you wish us to know about.Via EmailWe cannot send any clinical information via email, but, if you register for our ‘online services’ we can communicate via your secure online account – ask our staff for details it only takes 10 minutes to register with us – I.D. is required.Hearing impairedIf you are hearing impaired or deaf we can support you with a number of communication methods please tick all that you may wish to use. By letter By text It's OK to phone meOther information about hearing impairmentPlease include any other information you want to provide about a hearing impairment.Telephone contactWe know that some patients may have adapted assisted technologies which enable them to take phone calls - Tick all that apply. It’s ok to phone me It’s ok to phone my carer By textTelephone contact further informationOther information you want to provide about telephone contactWhat other support might you need?Our Practice Team will do their best to support you with your needs this may also include referral with your permission to the many support services in North Kirklees. Please include any further support requirements you may have.Alternative languagesWe have telephone interpreter services to help you with translation. Please include information about any other languages support you may require.