GRx Self-Referral request form

Full Name (of person being referred) *

Date of birth *

Address *

Phone number *

Email address *

If your med centres is NOT listed make direct contact to request a referral

You (Or the person being referred) must meet all the following criteria: *

18 years or older

inactive (<2.5 hours physical activity per week)

Want to increase physical activity

motivated for change

Name ( if completing this referral for someone else)

Profession

Contact details *

Consent to the West Coast Primary Health Organisation Green Prescription team contacting Medical Centre for further information

I consent OR

I have discussed this with the referee and they have provided consent

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