GP Registration

By requesting GP Exercise Referral resources using this online form you are agreeing to the following;

The referring doctor accepts clinical responsibility for the patient in that they agree to select patients within the recognised referral categories and who are suitable for the low to moderate intensity activities. The doctor will highlight on the referral form any activities that could be detrimental to the health of the patient or any precautions that should be taken. On the basis of the history and examination the referring doctor will refer patients who have no medical contraindications to participating in a suitably instructed exercise programme.

Information leaflets and posters will be supplied to the registered practice and the GP will ensure patients become aware of the programme through the display of these resources. Once registered, GP practice details will be displayed as part of the GP Exercise Referral website.

Please now complete below to state that you understand and agree to the above conditions with respect to the referral of my patients under the HSE-ILAM GP Exercise Referral Programme;

GP Details

1. Surname*
2. First Name*
3. Tel*
4. Fax*
5. Address*
   
   
6. Email*

1. I fully agree to the protocols and procedures.

There were errors on the form, please make sure all required fields(*) are fill out correctly.