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Person's Details

Name*

First Last

Date of Birth*

Day

Month

Year

Gender*

Please specify gender

Ethnicity*

Known Health Conditions*

Cardiovascular disease

High cholesterol

Hypertension

Osteoarthritis

Sleep apnoea

Type 2 diabetes

Anxiety

Depression

Chronic back pain

Asthma

COPD

Bronchitis

Pneumonia

Other

Prefer not to say

Please specify other known health conditions*

Person's Contact Details

Email*

Phone

Mobile*

Address*

Town*

Post Code*

Person's GP Details

GP Name*

Town your GP is located in*

GP Practice*

GP Practice*

GP Practice*

GP Practice*

GP Practice*

Referral*

Are you filling in this form on behalf of a patient, or is this a self-referral?

I am filling in the form on behalf of a patient

This is a self-referral

How did you find out about our services?

Referrer's Details

Referrer's Name*

Please enter the name of the professional who referred you

First Last

Organisation*

Email*

Phone*

Additional Details

We just need some final details in order to complete your referral to the East Lancs Health programmes

How did you hear about the East Lancs Health programmes?*

What was your motivation for signing up for the programme today?*

Meet people

General health

Improve fitness

Feel better

Sleep better

Lose weight

Improve breathlessness

Improve confidence

General wellbeing

Be there for family

Other

Prefer not to say

Please specify your motivation for signing up*

Consent*

The person being referred is over 16 years old, they have consented to the referral, and having their details recorded

Consent*

I confirm that I am over 16 and I consent to my details being recorded

Consent*

I do not have any unstable/uncontrolled conditions that may prevent me from exercising

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