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Email: specialistphysicalactivity@middlesbrough.gov.uk

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Patient Details (*Mandatory information)

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If this client/ Patient has a carer, then please add details below
If applicable, who can we talk to regarding this person (e.g. Power of Attorney)

Reason for Referral *

Long Term Conditions

If you wish to add a Long Term Condition not listed, you can add one using the free text option below.
Long Term Condition (Free Text)

Risk Factors

Referral Information *

Please provide additional details on the context of this referral, including any concerns or comments that may help us support the patient?

Data Sharing Statement

Middlesbrough aims to connect you with local services which may be able to provide you with information, advice and support. Sometimes it is necessary or helpful for us to share information with relevant organisations, for example your GP or a member of a care support team. This might be because they need to track which services you have been made aware of or are using. We will also provide statistical data to the funders of this service, although that information will be anonymised so you will not be identified.

You don’t need to agree to share your information but this would make it difficult to refer you to services you need. You have the right to get a copy of information held about you under the Data Protection Act however there are exemptions. If you’re worried about sharing your information, or would like to see a copy of information that is held about you, please contact Middlesbrough.

If you understand and agree to share your information please tick below.