Communication Needs

Do you have difficulty making yourself understood or understanding others?

Tell us about the person who helps you with communicating

Do you have a friend, a member of your family or a carer who will attend your appointments with you?

Yes No

If yes, would you like us to contact this person if we need to contact you or would you like us to speak or write to you first?

Please contact me only

Please contact my friend, family member/carer only

Please contact me AND my friend/family member/carer

If you have selected for us to contact your friend/family member/carer please tell us their name

Are they a friend, family member or carer?

Friend

Family member

Carer

Please give us their contact number

Do you have any other communication needs that we have not asked about?

Patient Declaration

I confirm that the information I have given is correct and where indicated I have given persmission for the Practice to make arrangements on my behalf, for example arranging an interpreter or contacting my carer.

I understand the information I have given on this form will be recorded in my medical records and shared with other health professionals when it is in my best interest to do so.

Important information for you

We will record the information you have given us in your medical records so that all our staff are aware of how they can help you.

If we refer you to another organisation, for example the Hospital, we will tell them about your communication needs to make communicating with them easier for you.

If your needs change at any time or you feel your needs are not being met, please let us know.

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Further Information