Download, print and complete this letter to ask for support from your doctor's surgery
Please give this letter to my doctor
Hello,
I have a
learning disability
A learning disability is to do with the way someone's brain works. It makes it harder for someone to learn, understand or do things.
and would like to be put on to your
learning disability register
The learning disability register is a list of people with a learning disability that the doctor’s surgery looks after.
(one of the NHS Quality and Outcomes Framework (QOF) indicators).
I would like some extra help to access the surgery.
These are the ways I would like to be supported:
Tick YES or NO to tell your doctor how you want to be supported:
I would like to get
Easy Read
Easy Read is a way of making written information easier to understand. Pictures are usually added next to the writing.
information and letters.
Yes â–¢ No â–¢
I would like to have extra time for my appointments.
Yes â–¢ No â–¢
I would like you to remind me about my appointments with a phone call or text.
Yes â–¢ No â–¢
I would like to see a doctor who knows me well.
Yes â–¢ No â–¢
I would like the doctor to use simple words and speak slowly.
Yes â–¢ No â–¢
I might need support to make decisions about my health.
Yes â–¢ No â–¢
I would like my appointment to be at a time that suits my needs.
Yes â–¢ No â–¢
I would like to be seen quickly because I find waiting hard.
Yes â–¢ No â–¢
I would like you to use pictures or objects to help me understand.
Yes â–¢ No â–¢
I have my own communication aids which you can use with me.
Yes â–¢ No â–¢
If you have any other support needs write them down here:
The best way you can contact me is by:
Text:
Yes â–¢ No â–¢
Phone:
Yes â–¢ No â–¢
Easy Read letter:
Yes â–¢ No â–¢
Other ways to contact me are:
I am happy to share extra information on my Summary Care Record.
About me
My name is:
My address is:
My email is:
My phone number is:
My signature is (please sign):
Todays date is:
______ / ________ / _________