Reasonable Adjustment Request

Please complete the form below to request reasonable adjustments. Your responses will help us provide the necessary support tailored to your needs.

Patient Details

Patient's Full Name *

Patient's Date Of Birth *

Patient's Full Address *

Contact Phone Number *

Email address on which you can be contacted *

Reasonable Adjustment Request Form

Impairment with substantial and long-term adverse effect on normal day to day activity. (This means you have a disability or health condition that makes it hard for you to do everyday things for a long time. For example, it could be difficult to walk, see, hear or remember things). Please describe your disability or impairment. *

Requires reasonable adjustment for health and care access. (This means you need changes or extra help to access healthcare services. For example, you might need information in large print, and interpreter or extra time for appointments, *

Can we share this information with other NHS providers? (Is it okay that we share your adjustments with other services in the NHS or social care? This will inform them of the reasonable adjustments you might need when they make contact or you see them. *

Yes: I consent for my reasonable adjustment data to be uploaded to the NHS spine and shared other NHS services

No: I DECLINE consent for my reasonable adjustment data to be uploaded to the NHS spine and shared with other NHS services

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Page last reviewed: 23 June 2026

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Reasonable Adjustment Request

Reasonable Adjustment Request

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