Download, print and complete this letter to ask for support from your doctor's surgery

A group people around a page representing the Learning Disability Register

Please give this letter to my doctor


I have a learning disability and would like to be put on to your learning disability register (one of the NHS Quality and Outcomes Framework (QOF) indicators).

A building with an open door and a ramp up to it. On the wall is a sign which says Doctor's surgery

I would like some extra help to access the surgery.

Two men standing next to each other. One is showing the other a piece of paper

These are the ways I would like to be supported:

A young woman reading an Easy Read booklet

Tick YES or NO to tell your doctor how you want to be supported:

I would like to get Easy Read information and letters.


Yes ▢           No  ▢

A clock showing 20 minutes has an arrow over it showing more time. This is above a picture of a doctor talking to a patient

I would like to have extra time for my appointments.


Yes ▢           No  ▢

A landline and a text phone

I would like you to remind me about my appointments with a phone call or text.


Yes ▢           No  ▢

A woman in a wheelchair is talking to her doctor at her desk

I would like to see a doctor who knows me well.


Yes ▢           No  ▢

A doctor with a speech bubble

I would like the doctor to use simple words and speak slowly.


Yes ▢           No  ▢

A man is sitting next to a young woman who is being given test results by a doctor

I might need support to make decisions about my health.


Yes ▢           No  ▢

A woman having her doctor appointment at 10:35

I would like my appointment to be at a time that suits my needs.


Yes ▢           No  ▢

A man looking fed up with a clock in front of him

I would like to be seen quickly because I find waiting hard.


Yes ▢           No  ▢

2 people sitting at a table.  On the table is a mat with picture cards on it.

I would like you to use pictures or objects to help me understand.


Yes ▢           No  ▢

A woman using a communication aid that sits on a desk

I have my own communication aids which you can use with me.


Yes ▢           No  ▢

A woman in a wheelchair with a speech bubble that reads "I need..." with a clock, easy read page, and ramp representing reasonable adjustments.

If you have any other support needs write them down here:

Two hands are using a mobile phone to text someone

The best way you can contact me is by:



Yes ▢           No  ▢

A woman on the phone calling her doctor who is in a blue circle behind her



Yes ▢           No  ▢

A complicated form with a red cross over it and an easy read form with a green tick over it

Easy Read letter:


Yes ▢           No  ▢

A woman in a red beanie hat is writing something down at a desk

Other ways to contact me are:

A computer with the words NHS Summary Care Record on it. Around the computer are pictures of medicines, food, files, a booklet, someone using a communication aid, and someone helping someone who has collapsed

I am happy to share extra information on my Summary Care Record.

Please help me to share extra information on my Summary Care Record.


Yes ▢           No  ▢

About me

A woman holding a sign with her full name written on it

My name is:

A rectangle
A house with an envelope with the address written on it

My address is:

a computer screen showing an email address

My email is:

A rectangle
A landline and a text phone

My phone number is:

A rectangle
A hand holding a pen writes a signature along a line

My signature is (please sign):

A rectangle
A page from a calendar which says 'Today' with the date, month and year numbers underneath it.

Todays date is:


______ /  ________ /  _________