Adjustments for patients with disabilities – Dr Sivakumar & Dr Gude's Surgery

If you have a disability, you can let us know how to help you access healthcare at the surgery.

This is also known as “reasonable adjustments.” You may also have heard the term “reasonable adjustments flag.”

Please fill in the form below to let us know what we can do to help you access services at the surgery.

You may need to ask a carer, friend or relative to help you.

If you would rather speak to someone, please phone or visit the surgery. We can then write your requirements into your care record.

Patient name(Required)

First name(s) Last name

Patient NHS number (if known)

Daytime telephone number(Required)

Date of birth(Required)

Address(Required)

Email(Required)

Enter Email Confirm Email

What we can do to help you access services at the surgery?(Required)

Not for urgent medical help(Required)

Yes, I understand this form is NOT for urgent medical help

Name

This field is for validation purposes and should be left unchanged.