Health & Wellbeing Referral Request

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.

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Referral Information

    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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Page last reviewed: 15 February 2021
Page created: 20 January 2021