Exercise for Health Form Information Name * Address Line 1 * Address Line 2 Postcode * Telephone Number * Email Address Please select your preferred centre * Bramcote Leisure CentreChilwell Olympia Sports CentreStapleford Community PavilionGreasley Sports and Community Centre Date of Birth * Please check this box if you are completing this form for someone aged 15 or under. Applicant aged 15 or under Parent / Guardian's Name Parent / Guardian's Phone Number Parent / Guardian's Email Address Reasons for Recommendations Please tick all of the reasons for this referral * Asthma COPD Risk Factor(s) for Osteoporosis Diabetes Hypertension Muscular-Skeletal Problems Overweight Raised Cholesterol Depression / Anxiety Disability Cancer Mental Health Parkinsons Are you referring into The Cardiac Rehab Phase 4 Scheme? Yes No If you answered yes to the question above, please upload a copy of a completed Cardiac Rehab Phase 3 BACPR form Drop a file here or click to upload Choose File Maximum file size: 16.78MB Are you referring into The Stronger with Parkinsons Scheme? Yes No Medical / Additional Information * Tick to confirm inactivity for more than 30 minutes a week Access Requirements Date of Recommendation * * By ticking this box, you are confirming your Healthcare Professional has recommended you for independent exercise and you agree to exchange the relevant information with Liberty Leisure Limited to be used in accordance with the privacy notice - https://www.lleisure.co.uk/privacy-notice/ Health Professional's Details Name of Health Professional * Address of Health Professional Line 1 * Address of Health Professional Line 2 Postcode of Health Professional * Phone This information will be used in accordance with our privacy notice. Please see our website for full details here Email Referral Confirmation Referral Confirmation * If you are the referrer – By ticking this box you confirm that you have informed your patient that you are sharing their data with Liberty Leisure Limited If you are a self referral – By ticking this box you confirm that you agree to your data being shared with Liberty Leisure Limited If you are human, leave this field blank.