Practitioner Referral Form


Consent to record information *    
Firstname *
Lastname *
DOB *
Email
Email allowed    
Mobile *
SMS allowed? *    
What service or services are required? *
Anything else we should know?
Referrer Name *
Please let us know if you would like to be added to our database to receive information by email (using the address you have provided) from Better Health North Somerset *    
Referrer Email Address *
Referrer Phone Number
Organisation you work for *
If organisation not listed above, please provide organisation name
What is your role? *



There has previously been some concern that long-term conditions could be made worse by physical activity. However, the evidence is that physical activity has an important role to play in preventing and treating many conditions and that, for most people with long-term conditions, the benefits outweigh the risks. This expert consensus, supported by the Office for Health Improvement and Disparities, will help healthcare professionals to have informed, personal conversations with their patients living with long-term conditions. (Moving Medicine Risk Consensus)
If health care / medical professional: do you sign off this person as safe to undertake increased Physical Activity? *