Health Gym Preferred Activities Nordic Walks Swimming Cycling Classes (Please Tick as many as Healthy Hips and Into Sport sessions appropriate) Hearts Ethnicity (please as appropriate) Referral Agent details Name Organisation Contact number Landline: Mobile: Email Date of Referral Please indicate any activities that medically, you recommend the referral should not engage in Please indicate the best time for us to contact and the easiest way to contact the referral / email – (please tick to confirm) Consent verbal consent has been obtained to share – the patients details with Trafford Leisure DECLARATION (please sign) We do not wish for this person to exercise if it may be unsafe. By signing this form you agree that, to the best of your knowledge, this person is suitable to undertake physical activity and it will not be detrimental to their health. Please return: Active Living Team, Marsland House, 3rd Floor, Marsland Road, Sale, M33 3AQ Or scan to
Preferred Activities (Please Tick as many as appropriate) Health Nordic Walks Cycling Healthy Hips and Hearts Gym Swimming Classes Into Sport sessions Ethnicity (please as appropriate) Referral Agent details Name Organisation Contact number Landline: Mobile: Email Date of Referral Please indicate any activities that medically, you recommend the referral should not engage in Please indicate the best time for us to contact and the easiest way to contact the referral – / email Consent – verbal consent has been obtained to share the patients details with Trafford Leisure (please tick to confirm) DECLARATION We do not wish for this person to exercise if it may be unsafe. By signing this form you agree that, to the best of your knowledge, this person is suitable to undertake physical activity and it will not be detrimental to their health. (please sign) Please return: Active Living Team, Marsland House, 3rd Floor, Marsland Road, Sale, M33 3AQ Or scan to
trafford_leisure-referral_form_may_2017.docx