Health & Wellbeing Referral Request

The Health & Wellbeing Team welcome referrals for those patients with long-term lifestyle related health conditions (such as type 2 diabetes, obesity, high blood pressure) that, with support are willing and eager to make sustainable healthy behaviour change to improve their own wellbeing. By completing this form you can express your interest at referral and the College Lane Surgery Team will review your request and if appropriate, make a referral to the Health & Wellbeing service, who will contact you directly. If we require any further information to assist in your referral or we feel you may need alternative support then we will be in touch.

Last Updated: 15/02/2021

Your Details

Name *

Date of Birth *

Phone Number *

Email Address *

Referral Information

Best time to contact you *

Reason for Referral Request (Tell us why you would like to access the Health & Wellbeing Team and what you would like them to help you with) *

Do you receive any help or support from any other services?

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA. *

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Health & Wellbeing Referral Request

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