Medical Referral for Exercise Form ESC Kingsdown Below to be completed by a qualified medical practitioner. Please complete this form with your patient as both of you are required to e sign this form. Referrers Name * First Name Last Name Referrers Position * Referrers GMC Number * (###) ### #### Practice Name * Practice Number * Practice Email * Date of Referral * MM DD YYYY Do you recommend your patient for the ESC Kingsdown referral scheme? * Yes No Do you agree that there is no medical reason for non-participation * Yes No Do you agree to inform the medical referral team at ESC Kingsdown of any changes in your patients circumstances? * Yes No Signature of Medical Practitioner * Below is to be completed and e signed by the Patient Patients Full Name * First Name Last Name Date of Birth * Email * Phone * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country GP Surgery * GP's Name (if different to referrer) Do you consent to take part in this scheme? Yes No Do you consent to share your details with the scheme? Yes No Has the scheme been fully explained to you and you your commitment required to it? Yes No Signature of Patient * Thank you for submitting your medical referrals application! We will be in touch within 48 hours. Regards ELITE Sports UK ESC Kingsdown, Portland Street, Bristol, BS2 8HL
