Skip to main content Skip to site footer

CARE Referral Form

    Gender

    Medical History

    Cancer Treatment
    Please list any side effects

    Equal Opportunities

    Ethnicity

    Emergency Contact Details

    Consent

    Self-Referral Declaration (pre and during treatment): If I am receiving, or about to receive any of the following treatments: chemotherapy, radiotherapy, targeted therapy, hormonal therapy or surgery – I will consult with my clinical specialist nurse specialist prior to starting the physical activity programme. Should there be something that affects my ability to exercise or I have a change in medication, I will inform the instructor immediately and stop exercising if necessary.
    Data Protection: We keep your records confidentially and securely. From time to time, our partners ask for information for monitoring & evaluation purposes to help us improve our service. Please tick this box if you consent to this.
    Filming and Photo Consent: I understand that from time to time, photographs or filming will be taken during the CARE sessions. All such photography and filming will be carried out by a Notts County FITC-approved person and used to promote the CARE programme. Please tick this box if you consent to this.