Patients with a Hearing Impairment Form

To enable the practice to support patients with a hearing impairment we wish to assess if there is a need for additional communication support, before their appointment e.g. lip reading or access to a hearing loop.

This information will be stored on the patient record to alert members of the healthcare team to any specific communication needs.

To enable this to happen, please complete this form.

Patients with a Hearing Impairment Form

Section

Type of Hearing Loss:
What would help me during my appointment:
The best way to contact me is:
I would like to use the following digital technology during my appointment:

Please can you ensure this information is recorded and flagged on my patient record, in accordance with NHS England's Accessible Information Standard.

Find out more by visiting: www.england.nhs.uk/ourwork/accessibleinfo