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THE HALL PRACTICE: Specific Needs Form
Please detail below any specific needs you have so the Practice can ensure they are identified and accommodated by taking the appropriate action:
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Full Name:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
NHS Number:
*
Your answer
Please state any Sensory Impairment you have (i.e. Speech, Hearing, Sight):
Your answer
Are you an ‘Assistance Dog’ User?
*
Yes
No
Please state any Physical disabilities you have:
Your answer
Please state any Mental disabilities you have:
Your answer
Please state any requirements you have to be able to access the Practice premises:
Your answer
Please state any Religious or Cultural needs:
Your answer
Do you require the help of a Translator / Interpreter?
*
No
Other:
Please state any specific nutritional requirements you have:
Your answer
Please state any allergies and sensitivities you have:
Your answer
Please state any phobias you have:
Your answer
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