Referral form

During the current COVID 19 pandemic, the Kent & Medway Prehab team has moved to remote service delivery and are continuing to accept new referrals and support existing programme participants via telephone and video call appointments. Patients are to be advised that their service provision will be home-based using a tailored home exercise programme, sent to them either via e-mail or the post, and the instructors will still provide regular support via telephone and digital platforms.

  • About you (person making the referral)

  • About your patient (person being referred)

  • (either patient's or a relative's/carer's mobile number)
  • PLEASE PROVIDE A BP READING AND RESTING HEART RATE. THIS IS ESSENTIAL TO ASSESSING THE SAFETY OF HOME EXERCISE FOR PATIENTS DURING THE COVID 19 PANDEMIC
    Please let us know of any pre-existing health conditions and/or other concerns which may impact on a patient's ability to participate fully in this programme for example but not limited to: moderate to severe mental health symptoms, learning disabilities, sensory loss, cognitive impairment or other conditions. It is recommended for patients with such needs to attend their first assessment session with an appropriate family member or carer.
  • Relevant Medical History

  • Please let us know particularly if the person being referred has any cardiac risk or other health conditions which could impact on their ability to participate in intensive exercise.
  • Nutritional Status

  • Please include any relevant information including recent weight, BMI, IDDSI descriptor or nutritional screening scores.
  • About the patient's GP

  • About the patient's cancer consultant

  • About the patient's Cancer Nurse Specialist (CNS)

Thank you!

Your self-referral has been successfully sent, we'll be in touch shortly.

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