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Home - Referral Form – diabetes (type 1 and 2)

Referral Form – diabetes (type 1 and 2)

Title*
First name*
Surname*
Address*
Postcode*
Date of birth*
How should we contact you? Please enter your tel number or email address
Telephone
Email
Family doctor*
Practice address*
Are you happy for us to contact your GP if we need further information about your health?*
- Yes
- No
Which diagnosis do you have?*
- Type 1 diabetes
- Type 2 diabetes
Date of diagnosis (if known)
Any other related health conditions*
- Yes
- No
If yes please list
Are you currently taking any medication(s)?*
- Yes
- No
If yes please list
These are group sessions but we have a limited number of one-to-one appointments for those who need them. If you feel a group setting is not suitable for you please indicate why:
How did you hear about this course?*
Is English your first language?*
- Yes
- No
Do you have any communication needs such as an interpreter?*
- Yes
- No
If yes, please specify
Do you have any sensory impairments that may require adjustments such as British Sign Language (BSL) signer or a requirement for information in alternative formats e.g. large print, audio, braille, easy read?*
- Yes
- No
If yes, please specify
Do you have a learning disability?*
- Yes
- No
Do you have Autism/ASD?*
- Yes
- No
Could you tell us more about your needs/requirements and any reasonable adjustments we could make to improve your experience?
Consent*
I have read, understood and agree to the terms outlined in the privacy policy.
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