Accessible Information Formlogo

Title (required)

First Name (required)

Surname (required)

Email Address (required)

Please tell us what format you need information in? (required)

Do you need anyone to come to appointments with you? (required)

Please tell us how we can support you: (required)

Please explain what support would be most helpful to you:

Click the check box to confirm you have read the Disclaimer below and wish to submit this online form to Lapworth Surgery, Old Warwick Road, Lapworth, Solihull, West Midlands, B94 6LH
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Disclaimer

Although sending information across the Internet means that privacy of data cannot be absolutely guaranteed, our online forms offer high levels of security. The forms use HTTPS and SSL (using a 64 bit certificate) to encrypt data sent to and from your computer when using the site and our server environment is PCI DSS certified – the highest standard of security associated with e-commerce and online finance solutions.

Form submissions are stored on the server for 28 days and are encrypted using DES Encryption paired with RSA Encryption, secured with a private key known only by the GP Practice.

Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.