MOVE 4 YOU REFERRAL FORM

REFERRER DETAILS
PATIENT DETAILS
DIAGNOSIS






Currently undergoing cancer treatments?
Yes No

Previous cancer treatments?
Yes No


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.