MOVE 4 YOU REFERRAL FORM

MOVE 4 YOU REFERRAL FORM

REFERRER DETAILS

Referrer Name

Referrer Email

Referrer Telephone

Referrer Extension

Referral Site

Other Referral Site

GP Surgery Name

Hospital

Referral Location

Other Referral Location

PATIENT DETAILS

First Name

Last Name

Date of Birth

Address

Post Code

Email

Borough

Telephone

Mobile

Gender

Other Gender

Ethnicity

White Other

Black Other

Mixed Other

Asian Other

NHS Number

DIAGNOSIS

Cancer Diagnosis

Other Diagnosis

Urgent/Pre-habilitation pathway or Rehabilitation

Cancer Type Notes (optional)

Specialty/Tumour Type

Other Co-morbidities

Medications

Please give full details on the above, including relevant dates

CONSENT

Confirm Patient Consent Obtained for:

• Joining the programme

• For relevant medical information to be passed to Tottenham Hotspur Foundation

• That Tottenham Hotspur Foundation will give feedback to my referrer whenever necessary

• Retention of electronic records by Tottenham Hotspur Foundation

The referral cannot be made without the patient’s consent

DATA PROTECTION

PRIVACY NOTICE: This privacy notice tells you how we will use your information in line with the law and your rights. We collect personal information from you so that we can give you the services you have signed up for and to make sure that these services are run in a safe, fair and equal manner. We will keep your information secure and will not share data with anyone outside the Foundation unless requested by service providers and unless we are required to do so by law or to prevent abuse or harm. We will keep your personal information for the length of the course and a one year follow up period, after which we will anonymise so you can’t be identified any longer.

If you have any queries please contact us on foundation@tottenhamhotspur.com.

Please tick to confirm you have read and understood the privacy notice.

Contact Information