Thanks for your application.

Thank you for your referral on to our Long-Term Conditions Programme.

A pre-assessment questionnaire will be emailed directly to your patient. Once completed, we will progress their referral.

Submit a referral to the Long-Term Conditions Programme

This programme is free to join. Please complete all required fields marked with an asterisk (*).

Location

Change location

This referral form is intended for use by healthcare professionals. Please confirm your eligibility below before proceeding with the referral.

I am a healthcare professional looking to refer a patient on to Nuffield Health's Long-Term Conditions Programme.*

Immediate Inclusion Criteria

Please read the following inclusion criteria, if any statements do not apply to the patient, the Nuffield Health Long-Term Conditions Programme will not be suitable:

Must be 18 years of age or over.
Can walk a minimum of 20 meters, with or without walking aids.
If a wheelchair is needed, they are an independent wheelchair user.
Is able to exercise without the use of an oxygen tank.
Has not had any surgery in the last 12 weeks and has been discharged from any post-operative rehabilitation/care.
Has no planned surgery in the next 24 weeks.
Is not pregnant.
Must be able to communicate verbally in English and be able to read English.
Must be ready to commit to participate in a group based 12-week rehabilitation programme.
Must be able to travel to the selected site, twice per week, for 12 consecutive weeks.

I confirm all of the above statements apply to the patient.

Patient Details

Patient First Name*

Patient Last Name*

Patient Date of Birth*

Patient Sex (at Birth)*

Patient NHS Number (Optional)

Patient Contact Details

Contact Number*

Email Address*

Address*

Town / City*

Postcode*

Clinical Status

Patient Symptoms Please select all symptoms that the patient experiences. You can choose more than one.*

Chronic Pain

Long-Term Fatigue

Breathlessness

Referring Healthcare Professional Details

Referrer First Name*

Referrer Last Name*

Referrer Email Address*

Practice Name*

Practice Postcode*

What is the occupation of the person making this referral?*

Please specify*

How did you hear about us?*

Please specify*

I agree to receiving updates regarding my patient from Nuffield Health*

I confirm that the patient has given consent to take part in this programme, and for Nuffield Health to contact them using the above details*

I confirm that the patient was provided information and direction to Nuffield Health T&Cs and Privacy Policy.*

I/My patient understands that as part of this programme, Nuffield Health will share anonymised data (data that can no longer identify the individual) with either Sheffield Hallam University or Manchester Metropolitan University.*

For information on how we handle your data, please see our Privacy Policy and our Community Rehab Programmes Transparency Statement.

Once you click submit, your patient will recieve a questionnaire to complete, once they have done this one of our Rehabilitation Specialists will contact them for an eligibility call to ensure the programme is suitable for them.