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Exercise Referral

Patient/Client details

Title
First Name Surname

Address
Post Code

Telephone No Mobile No

E-mail

Date of birth Ethnicity

Health referral declaration



Referral details

Practice

Title First Name Surname

Address
Post Code

Telephone No Mobile No

Fax No E-mail

Where did you hear about Fitsteps ?




NB: After pressing 'Submit' please allow access to the e-mailing program by clicking on 'Yes' in the next dialogue box before resetting and exiting the form.

 

Benefits


Walking, as a form of
exercise, may contribute
to a reduced dependence
on medication, quicker
convalescence and more
positive look on life.
Compared to other
exercise referral options,
it is also the simplest and
least expensive
alternative.

How do I refer ?

Please complete the
form on the left and
forward it to the Walks
Co-ordinator by pressing
the Submit button.

Alternatively, you can complete the form,
print it out and send it
by post to:


Walks Co-ordinator
Maldon District Council
Community Services
Freepost NAT 7194
Maldon
Essex CM9 5BR



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