Reasonable Adjustments Request Form

Health and care organisations must make reasonable adjustments to help people access services more easily. This includes support for:

People with learning disabilities
Autistic people
People with ADHD or other neurodivergent condtions
Physical or sensory disabilities
Dementia
Mental health conditions

We are committed to making any changes you need to feel safe, supported, and able to use our services.

Some adjustments may not be possible.
If that happens, we will try to find another way to help you access our services.

Please use the form below to tell us why you need support or adjustments. This includes changes for learning disabilities, autism, ADHD, or any other condition that affects access.

You don’t need to include all the details at this stage — the Practice team will review your submission and, where adjustments can be made, will contact you to discuss how we can best support you.

Step 1 of 2

Patient Information

Patient Name(Required)

First Last

Date of Birth(Required)

NHS Number (if known)

Patient's Phone Number

Patient's Email Address

Patient's Address

Street Address Address Line 2 City Post Code

Are you filling out this form on behalf of a patient?(Required)

Yes

Your Name

First Last

Your Phone Number

Your Email Address

What is your relationship to the patient?

Reasonable Adjustments Request Form

Patient Information

Patient Needs