Copyright 2019, The Weights Room Limited trading as The Exercise Studio Silverstream

MOVE YOU

WANT TO RECOMMEND A PATIENT?

This form is for Silverstream Health Centre to recommend a patient to participate in the MOVE YOU Program Pilot running from 5 October - 20 December 2019.   Please complete and submit the form below.

If your Medical Practice is interested in being involved with future MOVE YOU Programs, contact us here.

PATIENT INFORMATION

RECOMMENDATION - The patient is recommended for enrolment because he or she (PLEASE TICK):

Patient status after discussion

HEALTH CARE PROVIDER DETAILS & ACKNOWLEGMENT

Silverstream Health Centre?

By recommending the above patient as a participant in the MOVE YOU Program, you:

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  • confirm that he or she meets the agreed funding eligibility criteria; and

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  • confirm that you have obtained the patient's consent to make this recommendation and for a MOVE YOU team member to contact the patient directly using the details above.

What happens after you recommend a patient?

1.  We will contact the patient directly to discuss his/her suitability to participate in the Program.

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2.  We will confirm the patient's enrolment with you by email.

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