Secure Medical Referral Form

Please take some time to fill out this referral form with all relevant details.

If you have a file to attach, this can be added at the bottom of the page.

If you have a cardiovascular specific referral, please find our Phase 4 cardiac rehab referral form.

All data is encrypted through Wix platform which provides enterprise grade security: https://www.wix.com/website-security

Patient Details

First name

Last name

Date of Birth

Day

Month

Year

E-mail address

Contact telephone number

Multi-line address

Country/Region

Address

City

Zip / Postal code

Next of Kin / Emergency contact & relationship to patient

Next of Kin or Emergency contact telephone number

GP & contact (if known)

Medical Details

Reason for referral (provide details)

Most recent medical event, & intervention (please include any relevant details & any complications)

Current medical conditions (provide relevant details)

Previous history of medical conditions (provide relevant details)

Current / potential contraindications to exercise

Investigations

Please include any relevant investigations or tests & include findings / outcomes

Planned investigations & details eg: date

Further Information

List of current medications

BMI

Waist circumference

Recent Resting Heart-Rate

Recent Blood Pressure

Current exercise routine

Physical Activity Guidelines

Patient is currently meeting recommended Physical Activity Guidelines of at least 150 mins of moderate activity each week

Patient is currently meeting recommended Physical Activity Guidelines of at least 75 mins of vigorous activity each week

Most recent exercise programme details eg: sessions completed, heart rate achieved, RPE achieved, minutes completed, type of activities, symptoms alongside

Limitations & / or exercise considerations

Most recent exercise testing details eg: include test details, METs achieved (& predicted), heart rate achieved, RPE achieved, & reason test finished

Patient-centred goals

Any further information

At the time of transfer this patient is clinically stable

At the time of transfer this patient concords with listed medication

Follow up treatment plan

At the time of transfer this patient is NOT awaiting follow-up treatment

At the time of transfer this patient is awaiting follow-up treatment

Please specify

Signed

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Verbal consent given by patient

Date consented

If you are filling out this form for someone else, please state your full name, your role / your relationship with the patient, & your contact email address / telephone number

File upload