Section 1

Registration of a disabled person

Name

Title
If other, please specify
First name(s) *
Surname *

Date of birth *	Date of birth Month Day Year

Address

If the address is within North Lincolnshire, enter the postcode in the box below and then select "find address". If the address is outside of North Lincolnshire, or your address is NOT SHOWN in the list or is incorrect, you will need to enter the address in the boxes provided below.

Postcode *


Prefix e.g. first floor flat
House number/name *
Street *
Town/village
County
Country

Contact details

Telephone number *
Mobile telephone number

Email address

Additional details

Marital status

Name of your GP

GP's telephone number

Disabilities *

Blind
Partially sighted
Physically disabled
Other disabilities

Please note: We are unable to process your application to be registered as blind or partially sighted. Currently your request will need to go through Scunthorpe General Hospital where you will be seen by the ophthalmologist who can assess whether you qualify for registration. If you are classified as partially sighted or blind, the ophthalmology department will send your details onto us along with your certificate of vision impairment and we can proceed with the registration.

For more information please contact Scunthorpe General Hospital on 01724 282282.

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