AIS Communication Form Questionnaire AIS Communication Form Questionnaire At Stainland Road Medical Centre we want to make sure that we give you information in a way that is clear to you. Full Name Date of Birth Day Month Year Please answer the following questions to help us meet your needsWhen we write to you or contact you, do you need us to communicate in a particular way? Yes No If your answer is yes, please tell us which way you would prefer us to communicate with you. You may tick more than one box but please make your preference clear. By phone Optional I prefer to use the phone and I use a hearing aid Optional I prefer to use the phone and do not use a hearing aid Optional By email Optional I use a screen reader Optional I do not use a screen reader Optional By text message Optional I use a text to speak app Optional I do not use a text to speak app Optional With Easy Read pictures and words Optional By letter using large type Optional When you come to the surgery do you need a British Sign Language interpreter? Yes No If you need anything that is not on the list above, please tell our receptionist when you come in for your next appointment and we will do our best to meet your needs.