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Communication Support Request Form

If you are a patient, service user, carer or parent with a disability, impairment or sensory loss, you can use this form to request that we communicate with you in a different way.

Find out more about the Accessible Information Standard.

Unique ID

Your Details

What is your name?(Required)

Forename Surname

What is your home address?(Required)

Street Address Town / City Postcode

Are you registered with a GP?(Required)

Yes

No

What is your GP's name?(Required)

What is your GP's address?(Required)

Street Address Town / City Postcode

Do you know your NHS number?(Required)

Yes

No

An NHS number is a 10 digit number, like 485 777 3456. You can find your NHS number by logging in to a GP online service or on any document the NHS has sent you.

What is your NHS number?(Required)

What is your date of birth?(Required)

DD

MM

YYYY

How can we contact you?(Required)

Email

Letter

Phone Call

Text Message

What is your email address?(Required)

What number can we call you on?(Required)

This can be a landline or a mobile phone number.

When is the best time to call you?(Required)

What is your mobile phone number, so we can text you?(Required)

Communication Support

Who requires communication support?(Required)

Patient (me)

Relative / Carer (someone caring for me)

Please select all that apply.

When we contact you, how would you like us to communicate?(Required)

Standard letters are printed in 12 point font size.

Letter - No Adjustments (standard 12 point font)

Letter - Easy Read

Letter - at least 20 point font

Letter - at least 24 point font

Letter - at least 28 point font

Patients Know Best online system (existing users only)

Email

Braille (Grade 2)

Braille (Grade 1)

Phone Call

I want to opt out of all digital communications

Other (please specify)

My consent for data sharing(Required)

I agree that the hospital may need to share my details with the RNIB for the purpose of providing information in Braille.

What other method of communication would you want us to use?(Required)

What is your relative / carer's name, who requires communication support?

Forename Surname

Please confirm(Required)

I acknowledge that this person must know and agree that their details have been provided.

Do you know their NHS number?(Required)

Yes

No

An NHS number is a 10 digit number, like 485 777 3456. They can find their NHS number by logging in to a GP online service or on any document the NHS has sent them.

What is their NHS number?(Required)

What is their date of birth?(Required)

DD

MM

YYYY

What is their relationship to you?(Required)

How can we contact them?(Required)

Email

Letter

Phone Call

Text Message

What is their email address?(Required)

What is their home address?(Required)

Street Address Town / City Postcode

What number can we call them on?(Required)

This can be a landline or a mobile phone number.

When is the best time to call them?(Required)

What is their mobile phone number, so we can text them?(Required)

When we contact your relative / carer, how would they like us to communicate?(Required)

Letter - No Adjustments

Letter - Easy Read

Letter - at least 20 point font

Letter - at least 24 point font

Letter - at least 28 point font

Patients Know Best online system (existing users only)

Email

Braille (Grade 2)

Braille (Grade 1)

Phone Call

Other (please specify)

My relative / carer's consent for data sharing(Required)

My relative / carer agrees that the hospital may need to share their details with the RNIB for the purpose of providing information in Braille.

What other method of communication would they want us to use?(Required)

Name

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

We take your privacy, and the security and confidentiality of healthcare data, extremely seriously. This website has been built with security and confidentiality in mind.

Your IP address is never logged in our database.
Any person identifiable data you submit via this form is stored on a secure database server in England, which only the relevant authorised healthcare professionals can access.
All email notifications containing person identifiable data are sent securely through NHSmail.
Our processes for collecting data via this website have been approved by the Hull University Teaching Hospitals NHS Trust Information Governance Committee.
We are fully compliant with GDPR and the Data Protection Act 2018.
If you have any questions or concerns about this form, please contact the Communications Team.
View our Accessibility Statement.
Read our Privacy Policy.

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Built by the Communications Team