Secretaries: Fitter Futures

Fitter Futures Warwickshire services aim to support people across Warwickshire to improve their health. This may include maintaining a healthy weight, becoming more physically active and having a healthier lifestyle.

If you would like to be referred to Fitter Futures and gain access to their services then please complete the form below. This will be processed by the practice and a referral will be made. This process will be completed within 7 days of receipt of your secure form. Fitter futures will then contact to arrange an assessment.

If you want more information on fitter futures then please consult their website.

Contact details:

fitterfutures@warwickshire.gov.uk

01926 351077

Take part in our fitness club activities

Calculate your (Body Mass Index) BMI

Please do not write any symptom enquiries on this form. Any clinical information or request for appointments via this form will be discarded. To make an appointment either book online via the NHS app/Patient access or by calling reception 01926 331401. We will start to process your form by the next working day but it will take up to 5 working days to complete. We will send a referral to Fitter Futures and they will contact you with further details. If you are NOT a registered patient then your form will be discarded. This service is only for patients registered at the surgery aged 16 and over; and for parents or legal guardians of children. Forms must be completed in the UK due to GDPR regulations.

Secretaries: Fitter Futures

Name:

Gender

Address

Contact Number (Preferably Mobile):

Date of Birth (DD/MM/YYYY):

DisabilityIf you suffer no disability please state 'nil'

Ethnicity This is for research purposes. If you do not want to disclose then leave blank.

Body mass indexPlease use the online calculator linked at the top of the page

Reason for referral?Please let us know how you feel fitters future can help you.

What type of referral would you like?

What is your current smoking status?

How many units of alcohol do you consume per week?

Do you have any of the following mental illnesses?

Do have a learning disability?

Do you have a physical disability? If no State 'NO'. If yes, you must outline this above

Are you pregnant or recently given birth (Last 6 months)?

Privacy Protection

Information submitted through secure forms is used only for the purposes of processing your request. We may be in touch with you in relation to the information submitted.

All Information submitted through secure forms is secured with a private key and is accessed over a secure connection by nominated staff. We have a strict confidentiality policy.

This information is not shared with any third party organisations.

This information is retained for up to 28 days.

I consent to my information being used for the purposes described above and wish to submit this online form to Clarendon Lodge Medical Practice • Clarendon Lodge, 16 Clarendon Street, Leamington Spa, Warwickshire, CV32 5SS.

Learn more about our Privacy Policy and Terms of Use. Should you have any concerns about sending your personal details using the web, please use one of the alternative methods offered by our organisation.