NHS Diabetes Prevention Programme accessibility requirements
Please complete the short form below to inform us of any accessibility requirements you may have.
Name
*
First Name
Last Name
Name
Date of birth
*
-
Day
-
Month
Year
Date Picker Icon
Email address
Postcode
*
Street Address
Street Address Line 2
City
State / Province
Postcode
Postcode
*
Do you have a hearing impairment?
*
Yes
No
Please provide details:
Do you have a visual impairment?
*
Yes
No
Please provide details:
Do you have a speech impediment?
*
Yes
No
Please provide details:
Do you have any mobility issues?
*
Yes
No
Please provide details:
Please select any of the following that you would require if attending in person sessions?
Wheelchair access
Accessible toilet
Hearing loop system
Step-free access
Wide doorways
Public transport
Parking
Do you have any other accessibility requirements you would like us to know about?
Would you like to record an authorised user who can speak on your behalf?
*
Yes
No
Authorised user details
Authorised user 1:
Name
*
Full name
*
First Name
Last Name
Date of birth
*
-
Day
-
Month
Year
Date Picker Icon
Email address
*
Relationship to patient
*
Reason for being an authorised user
*
Please provide a memorable word
*
Authorised user 2:
Name
First Name
Last Name
Relationship to patient
Submit
Should be Empty: