Reasonable Adjustment Request Form

Request Reasonable Adjustments in your Healthcare

The NHS must make it as easy for disabled people* to use health services as it is for people who are not disabled. This is called making reasonable adjustments.

It is your right to ask for reasonable adjustments.

This could be the way you are treated or the things that you need when you visit your GP or are in hospital.

If you would like us and other NHS services to offer you reasonable adjustments, please complete and submit this form to the Practice.

Follow this link for information on the definition of a disability under the Equality Act 2010>>

PATIENT'S DETAILS

Patient's Full Name *

Patient's Date of Birth (DD/MM/YYYY) *

Contact Phone Number

An Email address on which you can be contacted *

DETAILS OF REASONABLE ADJUSTMENT REQUEST

What is your disability? *

What reasonable adjustments can we make? *

Can we share this information with other NHS Providers? *

Yes No

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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Page last reviewed: 24 June 2024
Page created: 26 February 2024

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Request Reasonable Adjustments in your Healthcare

Request Reasonable Adjustments in your Healthcare

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