Referral Form

Apollo Heath Group provide neurological therapy for both adults and children across the North West.

If you feel that we may be able to assist you or a family member please complete the attached referral form and a Clinical Lead will contact you to discuss your options.

Patient Details
First Name*
Last Name*
Date of Birth*
DD slash MM slash YYYY
NHS Number*

(if known)
Gender*
- Male
- Female
Address*
Street Address Address Line 2 City Post Code
Telephone Number*
Mobile Number*
Email*
Referrer Details
Referrer Full Name*
Referrer Role*
Referrer Company*
Referrer Contact Details*
Referrer Email*
Diagnosis and Reason for Referral*
Goal of Treatment and Expectations
Next of Kin Details
First Name*
Last Name*
Relationship*
Telephone Number*
Allergies and Medication
Allergies*
Medication(s)*
GP Details
GP Name*
Surgery*
GP Address*
GP Email*
GP Telephone Number*
Special Notes/Requirements
Comments
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Purpose/Activity	Type of data	Lawful basis for processing
To register you as a new customer	(a) Identity, (b) Contact	Performance of a contract with you
To process and deliver the products and services you request including managing payments, fees and charges, and to collect and recover money owed to us	(a) Identity, (b) Contact, (c) Financial, (d) Transaction, (e) Marketing and Communications	(a) Performance of a contract with you, (b) Necessary for our legitimate interests to recover debts owed to us
To manage our ongoing relationship with you which will include notifying you about changes to our terms, products and services, or privacy policy, to maintain our records	(a) Identity, (b) Contact, (c) Profile, (d) Marketing and Communications	(a) Performance of a contract with you, (b) Necessary to comply with a legal obligation, (c) Necessary for our legitimate interests to keep our records updated and to study how customers use our products/services
To administer and protect our business and our site (including troubleshooting, data analysis, testing, system maintenance, support, reporting and hosting of data)	(a) Identity, (b) Contact, (c) Technical	(a) Necessary for our legitimate interests for running our business, provision of administration and IT services, network security, to prevent fraud and in the context of a business reorganisation or group restructuring exercise, (b) Necessary to comply with a legal obligation
To deliver relevant content and advertisements to you and measure and understand the effectiveness of our advertising	(a) Identity, (b) Contact, (c) Profile, (d) Usage, (e) Marketing and Communications, (f) Technical	Necessary for our legitimate interests to study how customers use our products/services, to develop them, to grow our business and to inform our marketing strategy
To use data analytics to improve our website, products/services, marketing, customer relationships and experiences	(a) Technical, (b) Usage	Necessary for our legitimate interests to define types of customers for our products and services, to keep our site updated and relevant, to develop our business and to inform our marketing strategy
To make suggestions and recommendations to you about goods or services that may be of interest to you	(a) Identity, (b) Contact, (c) Technical, (d) Usage, (e) Profile	Necessary for our legitimate interests to develop our products/services and grow our business

Patient Details

Referrer Details

Next of Kin Details

Allergies and Medication

GP Details