Liverpool Weight Management Referral Form

Are you a Health Care Professional (HCP) completing this form on behalf of someone else?

Yes

No

Are you referring yourself as an individual (adult) only, or as a family referral (with at least 1 child)

I am referring only myself

I am a parent/carer of a child that needs support

Are you referring an individual (adult) only, or a family unit (with at least 1 child)

I am a HCP referring an adult

I am a HCP referring a family unit

Please enter your/referrer information below

Please enter your details below

Referrer Source

Referrer Name

First name(s)

Referrer Organisation

Last name

Referrer Job Title

Email

Referrer Email

Date of birth

Referrer Contact Number

Telephone

Please enter the (adult) client's information below

Please enter the primary adult/caregiver details below

Mobile

First name(s)

Address

Last name

Postcode

Email

Client Consent

Date of birth

Please enter details of the primary child

I consent to being referred to the Liverpool Healthy Weight Service. The nature and purpose of which has been explained by my GP/referrer

I consent to the release of relevant personal information about myself to the Liverpool Healthy Weight Service commissioned by Liverpool City Council.

I understand that under certain circumstances, the service may be required to return personal data to Liverpool City Council after the expiration of this contract.

I understand my information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controllers are my referring GP practice / referrer.

I understand that I have
(i) the right to change my mind about being referred to the service and to withdraw consent and
(ii) right of access to my information.

For more information on how your personal information is used please read our Privacy Policy which can be found here

Telephone

First name(s)

I consent to be referred to the Liverpool Healthy Weight service

Mobile

Last name

I give permission for my GP / referrer to be kept informed of my progress

Child BMI Centile

Address

Does the child you’re referring have special educational needs?

Postcode

Date of birth

Is child's address different from your own?

Address

Client Consent

Client Consent (to be agreed by client)

Please enter details of the primary child

Postcode

I consent to being referred to the Liverpool Healthy Weight Service. The nature and purpose of which has been explained by my GP/referrer

I consent to the release of relevant personal information about myself to the Liverpool Healthy Weight Service commissioned by Liverpool City Council.

I understand that under certain circumstances, the service may be required to return personal data to Liverpool City Council after the expiration of this contract.

I understand my information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controllers are my referring GP practice / referrer.

I understand that I have
(i) the right to change my mind about being referred to the service and to withdraw consent and
(ii) right of access to my information.

For more information on how your personal information is used please read our Privacy Policy which can be found here

First name(s)

I consent to be referred to the Liverpool Healthy Weight service

Last name

I give permission for my GP / referrer to be kept informed of my progress

Child BMI Centile

Does the child you’re referring have special educational needs?

Date of birth

Is child's address different from the adult?

Address

Postcode

Client Consent (to be agreed by client)

I consent to being referred to the Liverpool Healthy Weight Service. The nature and purpose of which has been explained by my GP/referrer

I consent to the release of relevant personal information about myself to the Liverpool Healthy Weight Service commissioned by Liverpool City Council.

I understand that under certain circumstances, the service may be required to return personal data to Liverpool City Council after the expiration of this contract.

I understand my information will be treated as confidential (although it may be used in anonymous form for statistical or research purposes) and that the data controllers are my referring GP practice / referrer.

I understand that I have
(i) the right to change my mind about being referred to the service and to withdraw consent and
(ii) right of access to my information.

For more information on how your personal information is used please read our Privacy Policy which can be found here

I consent to be referred to the Liverpool Healthy Weight service

I give permission for my GP / referrer to be kept informed of my progress