GP Referral Form

By signing the referral form, referring practitioners agree that: the details provided for the client's medical history and current medication are accurate. Please complete ALL parts of the form where applicable and provide a current list of medications and any other relevant information. Any missing data may result in a delay to the client being able to access Exercise Referral programmes. This form can be used to refer patients to either the Stour Centre, Julie Rose Stadium or Tenterden Leisure Centre.

Client's full name *

Client's date of birth *

Client's contact number *

Client's email address *

Client's address *

Preferred centre *

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 number (if different from referring practitioner)

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

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

If other, please state here

Current relevant medication or prescriptions

Other relevant medical conditions (current or previous)

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

GP Referral Form

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