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Client's Full Name *

Client's DOB *

Client's Contact Number *

Client's Email Address *

Client's Address *

Referrer's Full Name *

Referrer's Position *

Referrer's Contact Number *

Referrer's Email Address *

Referrer's Address *

Registered GP's full name (if different from referring practitioner)

Registered GP practice

Registered GP's contact no. (if different from referring practitioner)

Registered GP's Address (if different from referring practitioner)

Registered GP's email address (if different from referring practitioner)

Reason for referral * Disabilities Stroke Dementia Back Pain Stress Cardiac Inactive Overweight/Obesity (BMI 26+) Controlled Diabetes High Cholesterol Multiple Sclerosis Arthritis/Osteoporosis Hypertension Mental Health Emotional Wellbeing Joint/mobility problems/joint replacement Alcohol/Drug rehabilitation Asthma/COPD COVID 19 Rehabilitation Falls Prevention Other (please state)

If other, please state here

Current relevant medication or prescriptions

Other relevant medical conditions (current or previous)

Current medical information - Resting HR

Current medical information - BMI

Current medical information - Diastolic BP

Current medical information - Systolic BP

The Freedom Leisure Exercise on Referral Scheme has been fully explained to me and I wish to participate. I am aware that physical activity can be hazardous and there is a risk involved. I understand that my data will be stored confidentially on paper and electronically on a secure database and will be held in accordance with General Data Protection Regulations. I give consent for any relevant clinical information about my health and participation in this scheme to be used for evaluation and monitoring purposes. I give consent to be telephoned regarding my suitability for inclusion of any other selected services above. I give consent for my GP/referring health care professional to be kept informed of my progress and for the Exercise Referral instructor to contact me concerning my adherence to the scheme. * Client consent granted

I refer this patient in accordance with the Freedom Leisure Exercise on Referral Scheme guidelines above, which I have read and understood. I confirm that the client's GP is aware of and in agreement to this referral. * Practitioner consent granted

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