Healthier You Referral Form Please fill in and send to: Post: Healthier You HQ, 2nd Floor, East Wing, Graeme House, Liverpool L2 7ZH Secure e-fax: 020 8401 5162 Email: healthieryou.herefordshire@nhs.net We can also be contacted by phone on 0800 092 1191 Organisational data General medical practice code: If not known, please tick: No registered GP Practice Code not applicable Code not known Patient data NHS number: First language: Ethnicity: Family name: Given name: Address: Telephone: Email: Date of birth: Gender: Height (m.cm): Weight (kg): BMI: EMIS ID: VISION ID: Previous GDM: Yes: No: Blood test data Date: HbA1c: FPG: Reason for FPG: Please sign to confirm the individual understands that: On Learning Disability register? Yes: No: Not known / N/a: Is the individual recorded on SMI register? Consent statement Yes: No: Not known / N/a: Their personal and medical information is being shared The purpose of sharing this information is for them to participate on the programme Their personal and medical information will be stored securely on electronic systems and not be used for any purpose other than programme delivery The programme is delivered by Reed Momenta, with LloydsPharmacy, and data will be shared securely between both organisations for the purposes of delivering the programme effectively The results of preventative diabetes screening will be shared securely with their GP information may be shared with NHS England for programme evaluation purposes only Their data will be treated as confidential and held, shared and disposed of in line with all legal requirements (including the Data Protection Act) and NHS guidance (which includes the Caldicott Guidelines) I with the above statements Yes No Name: Date: Please mark here if you are recording any additional important information overleaf Service provided by
Healthier You Referral Form Please fill in and send to: Post: Healthier You HQ, 2nd Floor, East Wing, Graeme House, Liverpool L2 7ZH Secure e-fax: 020 8401 5162 Email: healthieryou.herefordshire@nhs.net We can also be contacted by phone on 0800 092 1191 Organisational data General medical practice code: If not known, please tick: No registered GP Practice Code not applicable Code not known Patient data NHS number: First language: Ethnicity: Family name: Given name: Address: Telephone: Email: Date of birth: Gender: Height (m.cm): Weight (kg): BMI: EMIS ID: VISION ID: Previous GDM: Yes: No: Blood test data Date: HbA1c: FPG: Reason for FPG: On Learning Disability register? Yes: No: Not known / N/a: Consent statement Please sign to confirm the individual understands that: Is the individual recorded on SMI register? Yes: No: Not known / N/a: Their personal and medical information is being shared The purpose of sharing this information is for them to participate on the programme Their personal and medical information will be stored securely on electronic systems and not be used for any purpose other than programme delivery The programme is delivered by Reed Momenta, with LloydsPharmacy, and data will be shared securely between both organisations for the purposes of delivering the programme effectively The results of preventative diabetes screening will be shared securely with their GP information may be shared with NHS England for programme evaluation purposes only Their data will be treated as confidential and held, shared and disposed of in line with all legal requirements (including the Data Protection Act) and NHS guidance (which includes the Caldicott Guidelines) I with the above statements Yes No Name: Date: Please mark here if you are recording any additional important information overleaf Service provided by